Replication of a local record keeping method for collecting road crash data in low resource settings: lessons from Bangladesh and Nepal.

BACKGROUND: Police road crash and injury data in low-income and middle-income countries are known to under-report crashes, fatalities and injuries, especially for vulnerable road users. Local record keepers, who are members of the public, can be engaged to provide an additional source of crash and injury data. METHODS: This paper compares the application of a local record keeper method to capture road crash and injury data in Bangladesh and Nepal, assesses the quality of the data collected and evaluates the replicability and value of the methodology using a framework developed to evaluate the impact of being a local record keeper. OUTCOME: Application in research studies in both Bangladesh and Nepal found the local record keeper methodology provided high-quality and complete data compared with local police records. The methodology was flexible enough to adapt to project and context differences. The evaluation framework enabled the identification of the challenges and unexpected benefits realised in each study. This led to the development of an 11-step process for conducting road crash data collection using local record keepers, which is presented to facilitate replication in other settings. CONCLUSION: Data collected by local record keepers are a flexible and replicable method to understand the strengths and limitations of existing police data, adding to the evidence base and informing local and national decision-making. The method may create additional benefits for data collectors and communities, help design and assess road safety interventions and support advocacy for improved routine police data.

Creating a difference - a role for the arts in addressing child wellbeing in conflict-affected areas.

BACKGROUND: Details findings from a project on the potential for arts activities and art therapy to support the mental health and wellbeing of children living in Kashmir. METHODS: The intervention engaged 30 school children over the course of one year who produced various forms of artwork and performances. In this paper, we report on project impacts, drawing on some of our qualitative measures including observations and interviews. RESULTS: Our research details impacts and improvements in areas of emotional expression, belonging, and agency. We also found an important role for schools to create safe, secure, and caring spaces to allow students to express themselves and work through traumatic feelings in a non-judgemental way. CONCLUSIONS: School-based arts interventions can play an important role in the mental health and wellbeing of children. Critical here, however, are dedicated space, time, and resources to provide a supportive environment and to sustain activity in long-term.

Factors related to adverse long-term outcomes after mild traumatic brain injury in children: a scoping review.

OBJECTIVE: To identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI). DESIGN: Scoping review of literature. PATIENTS: Children and adolescents with mTBI. RISK FACTORS: Any demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors. MAIN OUTCOME MEASURES: Postconcussion syndrome (PCS), recovery. RESULTS: Seventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature. CONCLUSIONS: The most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI.

Home environmental change for child injury prevention in Nepal: A qualitative study.

In Nepal, unintentional home injury is a leading reason for death and disability among pre-school children. However, there is a lack of evidence to inform culturally appropriate interventions to reduce home injuries. This study explored the potential for home environmental change at a community level to prevent unintentional home injury in children and identified the barriers to, and facilitators of, such changes. Focus groups were conducted in the Nepali language with mothers, fathers, teachers, school students and community health volunteers in rural areas of Makwanpur district in Nepal. The discussions were audio-recorded, transcribed, translated into English and analysed thematically. NVivo software was used to support coding and identification of themes. Five focus groups, involving forty-seven participants, were completed leading to the development of four themes. Overall, the findings highlight that community people perceive injuries to be a normal part of childhood and, therefore, few prevention measures were considered. Parents were, however, able to identify ways to change their environment that made it safer. Changes included removing hazards or adding safety equipment, adapting the home or restricting access to potential hazards. Barriers to implementation included limited awareness about injury hazards and risk management, poor quality housing and financial constraint. Facilitators included raising community awareness, acquiring resources and financial support and involving the family and community. Development of interventions to prevent injuries at home in pre-school children should reflect local context and culture; this is best achieved through engagement with parents.

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.

Educational interventions to prevent paediatric abusive head trauma in babies younger than one year old: A systematic review and meta-analyses.

BACKGROUND: Paediatric abusive head trauma (AHT) occurs in young children due to violent shaking or blunt impact. Educational and behavioural programmes modifying parent/infant interactions may aid primary prevention. This systematic review aims to assess the effectiveness of such interventions to prevent AHT in infants. METHODS: We searched Embase, MEDLINE, PsycINFO, The Cochrane library, CINAHL databases and trial registries to September 2021, for studies assessing the effectiveness of educational and behavioural interventions in preventing AHT. Eligible interventions had to include messaging about avoiding or dangers of infant shaking. Randomised controlled trials (RCTs) reporting results for primary (AHT, infant shaking) or secondary outcomes (including parental responses to infant crying, mental wellbeing), and non-randomised studies (NRSs) reporting primary outcomes were included. Evidence from combinable studies was synthesised using random-effects meta-analyses. Certainty of evidence was assessed using GRADE framework. PROSPERO registration CRD42020195644. FINDINGS: Of 25 identified studies, 16 were included in meta-analyses. Five NRSs reported results for AHT, of which four were meta-analysed (summary odds ratio [OR] 0.95, 95 % confidence intervals [CI] 0.80-1.13). Two studies assessed self-reported shaking (one cluster-RCT, OR 0.11, 95 % CI 0.02-0.53; one cohort study, OR 0.36, 95 % CI 0.20-0.64, not pooled). Meta-analyses of secondary outcomes demonstrated marginal improvements in parental response to inconsolable crying (summary mean difference 1.58, 95 % CI 0.11-3.06, on a 100-point scale) and weak evidence that interventions increased walking away from crying infants (summary incidence rate ratio 1.52, 95 % CI 0.94-2.45). No intervention effects were found in meta-analyses of parental mental wellbeing or other responses to crying. INTERPRETATION: Low certainty evidence suggests that educational programmes for AHT prevention are not effective in preventing AHT. There is low to moderate certainty evidence that educational interventions have no effect or only marginally improve some parental responses to infant crying.

Post-Crash First Response by Traffic Police in Nepal: A Feasibility Study.

BACKGROUND: Road traffic injuries are a significant and increasing public health burden in Nepal, but there is no national coverage of regulated and standardized emergency medical service systems. Therefore, this study was designed to develop a first responder trauma training program for the Nepal traffic police and to evaluate the feasibility of its delivery and follow up. METHODS: A training needs assessment with traffic-police officers in a single district of Nepal informed the development of a 3-day first-response course which was provided to officers in May 2019. Participants were supplied with a trauma-pack and asked to complete a report form when first-responder skills were used. Knowledge and confidence face-to-face surveys were used before and after training to assess learning, and were repeated at 6 months to assess retention of knowledge. The surveys at 6 months assessed the factors affecting application of first response skills. RESULTS: Most (97%) participants believed giving first-aid was part of their responsibilities and 95% had experience of transporting road crash victims to hospital with a range of injuries. Low levels of first-aid training and variable course content were reported. Knowledge and confidence scores improved post-intervention but were reduced at 6-months. During attendance at 303 road crashes in the 6-months follow-up period, 44% of the participants self-reported using at least one skill from the course; applying them on 92 occasions. Incident report-forms were frequently not completed. Barriers to providing treatment included: the patient already en-route to hospital when police arrived at scene; resistance to providing care from relatives or bystanders; and competing police duties (e.g., traffic management). CONCLUSIONS: Delivering a first-response training program for traffic-police in Nepal is feasible. Knowledge was retained and used, and skills were in frequent demand. A study of effectiveness and cost-effectiveness appears warranted to determine if extending the training to other districts can improve outcomes in road traffic injury patients in the absence of formal emergency medical services.

Identification of research priorities for suicide prevention in Nepal: a Delphi study.

BACKGROUND: Suicide is a significant public health concern in Nepal and there is a need for an evidence-based suicide prevention programme to facilitate stakeholders working towards suicide prevention in Nepal. Collaborative research between stakeholders focussing on shared priorities can help to prevent and control suicide. Hence, we aimed to develop a consensus list of research priorities for suicide prevention in Nepal. METHODS: The Delphi expert consensus method was used to elicit the prioritized research questions for suicide prevention in Nepal. Participants comprised suicide prevention experts (psychologists, psychiatrists, psychiatric nurses, researchers and advocates) and people with lived experience. Three rounds of Delphi were conducted; round 1: one to one interviews involving open ended questions used to generate research questions; round 2: ranking of the research questions using a 5-point Likert scale, and round 3: re-ranking of research questions in light of individual and group responses. RESULTS: Forty-two participants participated in round 1 followed by 38 in round 2 and 39 in round 3 . 522 research questions were generated through round 1 which were grouped together and reduced to 33 research questions sent for ranking in round 2. Using a cut off of at least 70% of the panel ranking questions as 'very important' or 'important', 22 questions were retained. These research questions were sent for re-rating in round 3 resulting in a final list of prioritized questions. CONCLUSIONS: This is the first expert consensus study to identify the top research priorities for suicide prevention in Nepal, and used experts in suicide prevention and those with lived experience. A consensus was reached regarding the studies needed to improve suicide data quality, assess the burden and identify factors associated with suicide. A priority driven approach to suicide prevention research may ensure that the research endeavour provides the most useful information for those whose day-to-day work involves trying to prevent suicide.

Identifying research priorities for road safety in Nepal: a Delphi study.

OBJECTIVE: To identify and prioritise the research needed to help Nepali agencies develop an improved road safety system. DESIGN: Delphi study. SETTING: Nepal. PARTICIPANTS: Stakeholders from government institutions, academia, engineering, healthcare and civil society were interviewed to identify knowledge gaps and research questions. Participants then completed two rounds of ranking and a workshop. RESULTS: A total of 93 participants took part in interviews and two rounds of ranking. Participants were grouped with others sharing expertise relating to each of the five WHO 'pillars' of road safety: (1) road safety management; (2) safer roads; (3) safer vehicles; (4) safer road users and (5) effective postcrash response. Interviews yielded 1019 research suggestions across the five pillars. Two rounds of ranking within expert groups yielded consensus on the important questions for each pillar. A workshop involving all participants then led to the selection of 6 questions considered the most urgent: (1) How can implementing agencies be made more accountable? (2) How should different types of roads, and roads in different geographical locations, be designed to make them safer for all road users? (3) What vehicle fitness factors lead to road traffic crashes? (4) How can the driver licensing system be improved to ensure safer drivers? (5) What factors lead to public vehicle crashes and how can they be addressed? and (6) What factors affect emergency response services getting to the patient and then getting them to the right hospital in the best possible time? CONCLUSIONS: The application of the Delphi approach is useful to enable participants representing a range of institutions and expertise to contribute to the identification of road safety research priorities. Outcomes from this study provide Nepali researchers with a greater understanding of the necessary focus for future road safety research.

Experience of living near a highway in Nepal: Community perceptions of road dangers in Makwanpur district.

Introduction: Road traffic injuries are a major but neglected global challenge. There are high and rising rates of road traffic injuries in Nepal. Most of the studies reporting these injuries in Nepal have used quantitative methods to describe the injury burden. Little qualitative research has been conducted to describe the contexts and social processes surrounding crashes, or public perceptions of risks and potential solutions. The aim of this study was to explore the perceptions of road dangers from communities living alongside a major highway in Nepal. Methods: In this qualitative study we recruited members of neighbourhood development committees and a mother's group to take part in focus groups exploring their views. Data were audio-recorded, transcribed, translated and analysed thematically. Results: Four focus groups were conducted involving 34 participants aged 24-65. Our study findings highlight the challenges faced by people living near a major highway and their fear of getting injured on the road. Five themes that emerged were: risky behaviours of road users, infrastructure for safer behaviour, poor condition and maintenance of roads and vehicles, limited adherence and enforcement of traffic laws, and the need for road safety awareness programmes. Conclusion: The community groups expressed multiple concerns regarding the safety of members of their communities and lived-in fear of death and injury on the road where they lived. There is an urgent need for government agencies to understand these concerns and to take action in relating to infrastructure provision, regulation and behavioural change programmes.

Completeness of police reporting of traffic crashes in Nepal: Evaluation using a community crash recording system.

OBJECTIVE: Accurate road crash reporting is essential for evaluating road safety interventions and plans. Under-reporting of road traffic crashes, injuries, and fatalities in police records has been widely described. The aim of this study was to apply and evaluate a community crash recording system, and assess the quality of the data in comparison with traffic police data in Nepal. METHODS: The crash data collection methodology involved recruiting Local Record Keepers working and living at locations known to be at a high risk of crashes. Six shopkeepers were recruited at three crash locations and trained to complete collision incident forms for crashes occurring over one year on the section of road visible from their premises. Manual traffic volume and pedestrian counts, and spot speed surveys were conducted. Data were compared with District police records for the same period and locations. RESULTS: Over 12 months, 110 crashes were recorded by the Local Record Keepers. Of these, 70 resulted in 145 injuries (5 fatalities, 62 severe, and 78 minor injuries), while 40 resulted only in property damage. Comparable police data recorded 23 crashes, of which 18 crashes resulted in 27 injuries (8 fatalities, 13 serious, and 6 minor injuries), and 5 crashes in property damage only. The difference in recording of fatal and serious injuries was statistically significant (χ2(1) = 19.94, p < 0.001). The police reporting rate was highest for fatalities (62.5%) but only 11.6% and 7.1% for property damage cases and minor injuries respectively, and 3.8% for single-vehicle crashes. Compared to the Local Record Keeper data, the overall police crash reporting rate was 19.7%. CONCLUSIONS: Local Record Keepers' recording of road traffic crashes and casualties is feasible and provides a more complete record than routinely collected police data. The low reporting rate in the police records of minor injury, property damage, and single-vehicle crashes suggest significant underestimation and bias in the reporting of the actual burden of road traffic crashes. Local Record Keeper recording is a viable method for validating police reports.

Views of professional stakeholders on readiness for a safe road system in Nepal; an exploratory qualitative study.

Road traffic injuries in Nepal are increasing despite being largely preventable. Little evidence exists regarding the barriers and facilitators to a safer road system. This study aimed to explore the perspectives of professionals whose jobs had the potential to influence road safety in Nepal regarding challenges and potential solutions. Semi-structured interviews with eight informants from diverse roles were analysed thematically. Three themes were identified: Modifying behaviours of road users; Road planning, construction and maintenance; and the Governance of roads and traffic. All participants considered the primary cause of crashes to be the negligent behavior of the road users, suggesting that improved knowledge would influence their decisions. Poor road design, building and maintenance, together with poor vehicle standards, and lack of investment and enforcement of existing road safety legislation, needed to be addressed through greater coordination of the agencies. The study identified a range of areas for future inquiry and action.

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.

State of Post-injury First Response Systems in Nepal-A Nationwide Survey.

Injuries account for 9.2% of all deaths and 9.9% of the total disability-adjusted life years in Nepal. To date, there has not been a systematic assessment of the status of first response systems in Nepal. An online survey was cascaded through government, non-governmental organisations and academic networks to identify first response providers across Nepal. Identified organisations were invited to complete a questionnaire to explore the services, personnel, equipment, and resources in these organisations, their first aid training activities and whether the organisation evaluated their first response services and training. Of 28 organisations identified, 17 (61%) completed the questionnaire. The range of services offered varied considerably; 15 (88.2%) provided first aid training, 9 (52.9%) provided treatment at the scene and 5 (29.4%) provided full emergency medical services with assessment, treatment and transport to a health facility. Only 8 (47.1%) of providers had an ambulance, with 6 (35.3%) offering transportation without an ambulance. Of 13 first aid training providers, 7 (53.8%) evaluated skill retention and 6 (46.2%) assessed health outcomes of patients. The length of a training course varied from 1 to 16 days and costs from US$4.0 to 430.0 per participant. There was a variation among training providers in who they train, how they train, and whether they evaluate that training. No standardisation existed for either first aid training or provision of care at the scene of an injury. This survey suggests that coordination and leadership will be required to develop an effective first response system across the country.

The prevention of - and first response to - injuries in Nepal: a review of policies and legislation.

BACKGROUND: Injuries, the cause of an estimated 4.5 million deaths annually and many more disabilities worldwide each year, are the predictable outcome of particular circumstances. One of the most effective ways to prevent injuries is through policy and legislation. The aim of this research study was to identify and critically review all policy and legislation in Nepal that had the potential to prevent injuries. METHODS: We identified legislation and policy that met inclusion criteria through a stakeholder meeting, networks and contacts, and websites and electronic resources. Each included document was critically reviewed to identify areas of strength and opportunities for improvement. We compared the included documents against WHO's recommendations of known effective interventions. RESULTS: Sixty-two documents met the inclusion criteria for this review. Of these, 24 (38.7%) were exclusively related to road injuries, 11 (17.7%) to occupational injuries, 6 (9.7%) to injuries in the home and 5 (8.1%) to injuries at school; 30 (48.4%) documents included text related to the first response to injuries. Of 127 strategic recommendations by WHO that provided an area for policy or legislative focus, 21 (16.5%) were considered adequately met by Nepali policy and legislation, 43 (33.9%) were considered partially met and 63 (49.6%) were not met. CONCLUSION: We drew five conclusions from this critical policy review, which we have related to recommendations as follows: widening the scope of legislation and policy for injury prevention to emphasize injuries occurring at home or school; addressing the causes of injuries and promoting proven preventive measures; greater clarity on both individual and institutional roles and responsibilities; trustworthy data and quality evidence to inform decision-making; and financial investment and capacity-strengthening for injury prevention and first response. The current system of federal governance in Nepal has potential for strengthening injury prevention and first response at the central, provincial and local levels.

Adolescent's perception of road risk on their routes to school in Makwanpur, Nepal; a qualitative study.

BACKGROUND: Busy and poor road infrastructure along routes to school poses high risk of traffic injury for children and adolescents. Ensuring every young person's safe journey to and from school is fundamental to achieving reductions in road injuries and Sustainable Development Goal 3.6. However, there is little evidence reporting adolescent's views about their school travel from low and middle income countries. This study aims to understand adolescent's perceptions of injury risks on their journey to school in Nepal. METHODS: We used Photo-Elicitation Interview (PEI) methods to collect data from fourteen purposively identified adolescents (12-16 years) who walk to Tribhuwan Secondary School along the East-West Highway which is known to be at high risk of crashes in Makwanpur, Nepal. The participants used a camera to record parts of their journey, which they perceived as dangerous or safe. Photographs were used as prompts during an interview afterwards. Interviews were audio-recorded, transcribed, translated and analysed thematically. RESULTS: The identified themes were categorised as either environmental or behavioural factors. The adolescents were scared to walk on narrow roadsides because of speeding vehicles. They also found crossing the road dangerous because of the lack of designated pedestrian crossings and disregard shown by drivers. Poor visibility caused by random roadside parking and trees also increased the sense of road danger. CONCLUSION: Adolescents expressed multiple concerns which made their journeys difficult and dangerous. They illustrated issues such as poor road condition, inadequate pedestrian crossings and traffic signs, narrow roadsides, vehicle speeding and overtaking, failing to obey traffic rules and regulation -providing evidence that could be shared with the authorities to improve road safety near schools.