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

Utility of routine data reporting injuries requiring hospitalisation in Nepal: A secondary data analysis

BackgroundInjuries are an important public health issue in Nepal, contributing significantly to both morbidity and mortality. There is no injury surveillance system available, however healthcare service use is routinely reported to central government using the Health Management Information System (HMIS). The study was conducted as part of a wider programme of research to explore the burden of injuries in nepal, funded by the UK National Institute for Health Research (Ref 16/137/49).ObjectivesTo explore the utility of HMIS data to understand the burden of injuries in Nepal, inequalities by age and sex and changes over time.DesignSecondary analysis of published dataSettingNepalData sourcesWe used published national HMIS data on hospitalised injuries in Nepal, between 2009/2010 and 2016/2017, classified using International Classification of Disease codes. We grouped codes to report data by injury type, using the Global Burden of Disease injury classification framework where possible. We calculated crude rates of total unintentional injuries and self-harm and crude rates by year for each type of unintentional injury, with correlation coefficients to describe any trends over time.Results The trend in crude unintentional injury rate increased over time. Road Traffic Injury (RTI) admissions increased from 4.28/100,000 (95% CI 4.03-4.52) population in 2009/2010 to 10.55/100,000 (95% CI 10.17 to 10.92) in 2016/2017 (r=0.93), while admissions following poisoning almost halved over the same period, from 7.52/100,000 (95% CI 7.19-7.84) to 3.62/100,000 (95% CI 3.40- 3.84) (r=-0.87). Inequalities by age and gender were noted; during the period 2014/2015- 2016/2017, admissions following RTI most commonly affected adults of working age (13.82/100,000; 95% CI 13.50 to 14.14), and were 1.78 times more common in men (13.63/100,000; 95% CI 13.27 to 13.99) than women (7.77/100,000; 95% CI 7.49 to 8.05).LimitationsThe coding and completeness of the injury data currently limit the utility of their use for monitoring and decision making.ConclusionsThe cause of injury admissions between 2009/2010 and 2016/2017 appears to have shifted over time, with trends varying by injury type. In the absence of an injury surveillance system, routine inpatient data collected through HMIS has the potential to inform policy and practice. Future workSupport to enhance the completeness of data collection and accuracy and consistency of data coding has the potential enhance the utility of this existing data system.Fundin

Barriers and facilitators to learning and using first aid skills for road traffic crash victims in Nepal: A qualitative study

BackgroundRoad traffic injuries are a major global public health problem despite being avoidable and preventable. In many low- and middle-income countries, the victims of road traffic crashes do not receive care at the scene and may die before reaching hospital. In low- and middle-income countries where prehospital emergency medical services are not well established, bystanders have the potential to save lives by providing first aid. Nepal has rising rates of road traffic injuries and emergency medical services are early in development. There is limited evidence on the factors that influence people in Nepal to become trained in first aid and to use their first aid skills. ObjectivesTo understand the barriers and facilitators to learning first aid and to applying those skills to help road traffic crash victims in Nepal.DesignQualitative study using semi-structured interviewsSettingKathmandu, Lalitpur, Bhaktapur, Kaski and Makwanpur districts in NepalParticipantsWe interviewed three groups of participants (i) members of the public who had never been trained in first aid, (ii) members of the public who had been trained in first aid (iii) first aid trainers. Data sourcesInterviews explored reasons why people may be interested in being trained and factors that would inhibit being trained or applying their first aid skills. Interviews were transcribed, translated into English, and analysed thematically.ResultsRespect from the public, a desire to help those in need, and confidence to apply skills were important factors encouraging people to learn and apply first aid. Barriers included lack of time and financial implications of providing first aid. The fear of social and legal consequences if the patient had a poor outcome, a lack of confidence to apply skills, and lack of trust shown to first aiders by some members of the community, discouraged learning and using first aid skills.LimitationsParticipants were mostly from urban and semi-urban areas. People with more difficult access to healthcare may have held different views. People who were untrained in first aid and agreed to participate may hold different views to those who were not recruited, as they had interest in the topic. ConclusionsMembers of public can be encouraged to learn and apply first aid skills to help road traffic crash victims, but there are multiple barriers to engagement in first aid. Providing legal protection from prosecution for first aiders, raising public awareness of the value of first aid, addressing financial constraints, and provision of refresher training may address these barriers.Future workResearch to address the barriers to the creation of a Good Samaritan law appear warranted. The perspectives of other groups often involved in the care and/or transport of RTC victims, such as taxi drivers would add to our understanding of factors affecting the application of first aid. The gendered stereotypes reported by female first aiders warrant further exploration

The burden of injuries in Nepal: Findings from the NIHR Global Health Research Group

Background: Injuries cause significant harm and may lead to disability yet are largely preventable. Understanding the epidemiology and determinants of injury in any given context is an essential step towards effective prevention. In Nepal, surveys suggest that injuries on the road, at home and at work are a problem, but in the absence of injury surveillance, robust death registration or police records, the true burden is unclear. For those who are injured, access to prehospital care is variable. Objectives: (i) To understand the epidemiology of injuries (ii) To identify potentially modifiable risk factors to inform the development of prevention interventions (iii) To build capacity and capability for injury prevention research.Design: Observational, secondary data analysis and qualitative methods were used. We worked with communities, practitioners and stakeholders to identify potential participants, develop study protocols and disseminate findings.Setting: Nepal.Participants: Patients, communities and road users, health system practitioners and managers, professionals (e.g. police, engineers, journalists) and local and national decision makers.Main outcome measures: epidemiological evidence of the burden of injuries, evidence to inform future intervention development. Data sources: participants, health services, police and information in the public domain.Review methods: Reviews were conducted systematically with evidence synthesised narratively.Results: The Nepal Injury Research Centre was established, and a cadre of researchers trained. Three researchers and our data manager completed Masters degree courses and all researchers developed their skills by leading at least one project from protocol development through to publication. A review of publications reporting injuries indicated that existing epidemiological evidence mostly arose from case series at high risk of bias. A review of existing legislation showed policy gaps and incomplete implementation or enforcement. Surveillance studies and a household survey showed the high burden of injuries at home, work and on the roads and the neglected issue of suicide. Previously unreported inequalities by age, sex, ethnic group and income level were identified. Existing health, police and death registration data systems are at high risk of under-reporting and misclassification. Road traffic injury emerged as a major concern; road users fear being injured as pedestrians, passengers or drivers, the economic burden of road injuries has increased three-fold over eight years and potentially modifiable risk factors were identified. The provision of first response services is highly variable, and the public and practitioners are fearful of prosecution in the event of poor outcomes. We found it is feasible to train the traffic police in first response and for them to use their skills at traffic collisions. Research priorities for suicide prevention were identified.Limitations: Studies were limited by the quality of the data available through existing systems, with data often incomplete or poorly coded. Our studies were largely conducted in one district with topography typical of many areas of Nepal. However, our findings may not be generalisable to all districts. Conclusions: Our programme identified the inequitable and significant burden of injuries in Nepal. There is the potential to develop existing legislation and health and transport systems to reduce the incidence and consequences of injury.Future work: Research should focus on interventions to reduce injury risk on the roads and at home/work, to develop the first response system and standardise care, and to strengthen injury data systems