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.

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.

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.

Global Community Child Health.

This special issue of IJERPH has published a range of studies in this developing field of Global Community Child Health research. A number of manuscripts submitted in response to our invitation describing 'community-based interventions which impact on child health and wellbeing around the globe. In addition to rural community-based initiatives given that most children now live in cities we are also interested to hear about urban initiatives….' We hope this issue will of great interest to the researchers and practitioners as well as academia from the fields of Global Health as well as Global Child Health because it comprised of 14 articles representing all five continents. Physical activity appears a key component of the scientific community's current conception of child well-being judging from the four papers published addressing this area. This issue also has papers on childhood obesity to rubella vaccination. Despite of the journal's strive for reaching out to a wider global child health community, this issue missed contributions relating to child safeguarding and social determinants of urban health.

Burden of injuries in Nepal, 1990-2017: findings from the Global Burden of Disease Study 2017.

BACKGROUND: Nepal is a low-income country undergoing rapid political, economic and social development. To date, there has been little evidence published on the burden of injuries during this period of transition. METHODS: The Global Burden of Disease Study (GBD) is a comprehensive measurement of population health outcomes in terms of morbidity and mortality. We analysed the GBD 2017 estimates for deaths, years of life lost, years lived with disability, incidence and disability-adjusted life years (DALYs) from injuries to ascertain the burden of injuries in Nepal from 1990 to 2017. RESULTS: There were 16 831 (95% uncertainty interval 13 323 to 20 579) deaths caused by injuries (9.21% of all-cause deaths (7.45% to 11.25%)) in 2017 while the proportion of deaths from injuries was 6.31% in 1990. Overall, the injury-specific age-standardised mortality rate declined from 88.91 (71.54 to 105.31) per 100 000 in 1990 to 70.25 (56.75 to 85.11) per 100 000 in 2017. In 2017, 4.11% (2.47% to 6.10%) of all deaths in Nepal were attributed to transport injuries, 3.54% (2.86% to 4.08%) were attributed to unintentional injuries and 1.55% (1.16% to 1.85%) were attributed to self-harm and interpersonal violence. From 1990 to 2017, road injuries, falls and self-harm all rose in rank for all causes of death. CONCLUSIONS: The increase in injury-related deaths and DALYs in Nepal between 1990 and 2017 indicates the need for further research and prevention interventions. Injuries remain an important public health burden in Nepal with the magnitude and trend of burden varying over time by cause-specific, sex and age group. Findings from this study may be used by the federal, provincial and local governments in Nepal to prioritise injury prevention as a public health agenda and as evidence for country-specific interventions.

Road traffic injuries in Nepal during COVID-19 lockdown.

Background: As the world is busy addressing COVID-19, road traffic injuries, another major cause of death is continuously killing people on the roads. In Nepal, there were frequent media reports of occurrences of road crashes, injuries, and deaths despite nationwide lockdown. This paper aims to describe the situation of road traffic crashes and casualties during the period of complete lockdown. Methods: This study used secondary data from two sources: Nepal Police and media reports between 24 March and 14 June 2020 (because the government lifted the nationwide lockdown from 15 June 2020). Available details of crashes, deaths, and injuries for this period were extracted from media reports and the summary data that was obtained from the Police.  We have included data from both sources in the results. Results: Nepal Police recorded 1,801 incidents of road crashes during the 82 days of the COVID-19 lockdown with 256 deaths (on average 3.1 deaths daily) and 1,824 injuries (on average 22.2 injuries daily). Motorcycles comprised over 21% of all vehicles involved in crashes. Ambulances and other vehicles for essential services were also found to be involved in crashes. Speeding itself was the cause for almost a quarter of the incidents during the lockdown. Conclusions: Although a reduction in the number of road crashes and related injuries and fatalities was observed, this reduction was not as substantial as anticipated during the heavy restrictions on vehicular movement imposed during the lockdown. Media reports were mainly found to be reporting the crashes where deaths occurred, but police records also included nonfatal injuries. The incidence of crashes in this period shows that it is important to work for road safety to save lives from road traffic crashes in Nepal.

Status of drowning in Nepal: A study of central police data.

Background:  Drowning is a serious and mostly preventable injury-related cause of death. Low-and-middle income countries represent over 90% of total drowning deaths worldwide. There is lack of epidemiological studies of drowning in Nepal. The aim of this paper is to describe the status of drowning in Nepal. Methods: Cases of drowning, occurring between 1 January 2013 and 31 December 2015 were extracted from the Daily Incident Recording System of Nepal Police. Drowning cases were extracted and analysed regardless of their intent. Variables on age, sex of the deceased, types of water bodies, geographical locations, season when drowning occurred and activities of deceased were extracted and descriptive analysis was conducted. Results: A total of 1,507 drowning cases were recorded over a 3 year period. The rate of drowning was 1.9 per 100,000 (2.95 for males and 0.92 for females). Majority of drowning occurred among males (76%) and more than half were (53%) under 20 years of age. Mostly drowning occurred in rivers (natural water bodies). The findings provide strong indication that drowning occurs throughout the year in Nepal. Children were highly vulnerable to drowning. The magnitude of drowning was found to be lower than estimated by global burden of disease (GBD) study. Conclusion: The burden of drowning in Nepal is considerable, but mostly unknown to the public. Despite only having access to a limited data source, this study provides useful evidence that comprehensive research in Nepal is needed urgently.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Informed Consent in Health Research: Challenges and Barriers in Low-and Middle-Income Countries with Specific Reference to Nepal.

Obtaining 'informed consent' from every individual participant involved in health research is a mandatory ethical practice. Informed consent is a process whereby potential participants are genuinely informed about their role, risk and rights before they are enrolled in the study. Thus, ethics committees in most countries require 'informed consent form' as part of an ethics application which is reviewed before granting research ethics approval. Despite a significant increase in health research activity in low-and middle-income countries (LMICs) in recent years, only limited work has been done to address ethical concerns. Most ethics committees in LMICs lack the authority and/or the capacity to monitor research in the field. This is important since not all research, particularly in LMICs region, complies with ethical principles, sometimes this is inadvertently or due to a lack of awareness of their importance in assuring proper research governance. With several examples from Nepal, this paper reflects on the steps required to obtain informed consents and highlights some of the major challenges and barriers to seeking informed consent from research participants. At the end of this paper, we also offer some recommendations around how can we can promote and implement optimal informed consent taking process. We believe that paper is useful for researchers and members of ethical review boards in highlighting key issues around informed consent.

Usefulness of hospital emergency department records to explore access to injury care in Nepal.

BACKGROUND: Injuries are a major public health problem worldwide. Despite increasing morbidity and mortality from injuries in Nepal, it is not recognised in the government's policy and programmes and few population-based studies have been published. This study describes the usefulness of hospital emergency department records to explore access to injury care in Nepal. METHODS: A retrospective ED-based study was conducted at a governmental hospital in Nepal to review the routinely collected data for 1 year (1 January 2010 to 31 December 2010). The study was designed to provide cross-sectional data to describe the distribution of injuries by age, gender, ethnic group and injury mechanism. RESULTS: Results showed that twice as many males as females attended the emergency department (14.6 vs. 7.0 per 1000), attendance varied by age with most (39.8 %) attendances in young adults of working age and over half of attendances were from just two ethnic groups (Brahmin (26 %) and Tamang (25.5 %). Road traffic injuries were the most common cause of injury (37.6 %). CONCLUSIONS: This study therefore showed the feasibility of using routinely collected hospital emergency department data to monitor injury inequalities in Nepal.

Epidemiology of Unintentional Child Injuries in the Makwanpur District of Nepal: A Household Survey.

Secondary sources of information indicate that the proportion of child deaths due to injuries is increasing in Nepal. This study aimed to describe the epidemiology of unintentional injuries in children, explore risk factors and estimate the burden faced by families and the community in the Makwanpur district. We conducted a household survey in Makwanpur, covering 3441 households. Injuries that occurred during the 12 months before the survey and required treatment or caused the child to be unable to take part in usual activities for three or more days were included. We identified 193 cases of non-fatal unintentional child injuries from 181 households and estimated an annual rate of non-fatal injuries of 24.6/1000 children; rates for boys were double (32.7/1000) that for girls (16.8/1000). The rates were higher among the children of age groups 1-4 years and 5-9 years. Falls were the most common cause of non-fatal child injuries followed by burns in preschool children and road traffic injuries were the most likely cause in adolescence. Mean period of disability following injury was 25 days. The rates and the mechanisms of injury vary by age and gender. Falls and burns are currently the most common mechanisms of injury amongst young children around rural homes.

The feasibility of community mobilisation for child injury prevention in rural Nepal: a programme for female community health volunteers.

BACKGROUND: Injuries accounted for 23% of all deaths in children and adolescents in Nepal during 2010 (n = 3,700). Despite this, there is no national death registration or injury surveillance system. Non-fatal injuries are many times more common than fatal injuries and may leave the injured person with lifelong consequences. Children in low-income settings are exposed to widespread risks of injuries but there is little awareness of how they can be prevented. Community mobilisation has been shown to be effective to reduce maternal and neonatal morbidity. This study aimed to develop a child safety programme and assess the feasibility of delivering the programme through a community mobilisation approach. METHODS: We developed a culturally appropriate, educational programme for Female Community Health Volunteers that included both primary and secondary prevention materials for unintentional child injuries. We determined the feasibility of evaluating its effectiveness through the mobilisation of women's groups in rural Nepal. Ten women's groups across 9 wards in one village development committee area completed the programme during 6 monthly meetings. Parent-reported injuries were collected through a notification system established for this study. Experience of the programme by women's group participants and leaders was assessed through a structured questionnaire and process measures assessed the delivery and reach of the programme. RESULTS: Programme resources were developed for this setting and adapted following feedback from users. Nine FCHVs received first-aid training and shown how to use the facilitation manual and injury prevention resources. The FCHVs convened 10 women's groups to run over 6 months with 24-29 mothers attending each meeting (290 mothers participated in total). Each group presented their views on child injury risks and proposed prevention activities at local public meetings. Women reported 155 injuries to children under 18 years during 7 months of follow up using the notification system. CONCLUSIONS: It is feasible to develop and implement a community mobilisation intervention where women's groups work together with local FCHVs to prevent injuries in children. The intervention was well received by the women's groups and by community members. The effectiveness and cost effectiveness of the intervention should now be evaluated through an experimental study.

Epidemiology of unintentional child injuries in the South-East Asia Region: a systematic review.

All the 11 members of the South-East Asia Region (SEAR) of the World Health Organization are categorised as low- and middle-income countries. This region has over a quarter of the world's total population but comprises about one-third of the world's unintentional injury-related deaths. There is a paucity of good-quality mortality and morbidity data from most of these countries. This is the first systematic review of community-based surveys on child injuries that summarises evidence from child injury studies from the SEAR countries. The included papers reported varying estimates of overall non-fatal unintentional injury rates across the countries, from 15/1000 children in Thailand to as high as 342/1000 children in India. The fatal injury rates were also found to be varying. This review revealed a need for strengthening child injury research using standard methodologies across the region and for promoting the dissemination of the results.

Community perceptions of unintentional child injuries in Makwanpur district of Nepal: a qualitative study.

BACKGROUND: In Nepal, childhood unintentional injury is an emerging public health problem but it has not been prioritised on national health agenda. There is lack of literature on community perceptions about child injuries. This study has explored community perceptions about child injuries and how injuries can be prevented. METHODS: Focus group discussions were conducted with mothers, school students and community health volunteers from urban and rural parts of Makwanpur district in Nepal. FGDs were conducted in Nepali languages. These were recorded, transcribed and translated into English. A theoretical framework was identified and thematic analysis conducted. RESULTS: Three focus group discussions, with a total of 27 participants, took place. Participants were able to identify examples of child injuries which took place in their community but these generally related to fatal and severe injuries. Participants identified risk factors such as the child's age, gender, behaviours and whether they had been supervised. Consequences of injuries such as physical and psychological effects, impact on household budgets and disturbance in household plans were identified. Suggestions were made about culturally appropriate prevention measures, and included; suitable supervision arrangements, separation of hazards and teaching about safety to the parents and children. CONCLUSION: Community members in Nepal can provide useful information about childhood injuries and their prevention but this knowledge is not transferred into action. Understanding community perceptions about injuries and their prevention can contribute to the development of preventive interventions in low income settings.