Case study: Preventing injury and improving trauma care in Nepal and worldwide
Getting injury on the public health agenda in Nepal
NIHR is increasingly focusing on research into prevention and timely treatment of unintentional injuries including those caused by road traffic collisions, falls, drowning, burns and accidents at work, which together account for around 3 million deaths every year and nearly 7% of the global burden of disease. More than 90% of injuries worldwide occur in low and middle income countries (LMICs) and they are one of the most preventable public health problems.
Injury prevention is relatively new to Nepal’s public health agenda, with injury rates and risks for harm not being formally recorded. Evidence suggests that road traffic injuries and natural disasters are the most common cause of trauma and related deaths in Nepal. For each injury-related death, around 1,000 people with non-fatal injuries visit emergency departments for treatment and hundreds of thousands are left with life changing disabilities. In addition to the physical or emotional trauma there are also personal and national financial consequences; for example, the estimated economic burden of road traffic injuries in Nepal has increased three-fold between 2008 and 2016.
Researchers working with the NIHR Global Health Research Group on Nepal Injury Research have established the Nepal Injury Research Centre (NIRC) at Kathmandu Medical College to address the impact of injury around the country. Led by Professor Julie Mytton, Professor of Public Health at the University of the West of England and NIRC’s Director, Professor Sunil Kumar Joshi, Professor of Community Medicine at Kathmandu Medical College, the Group has engaged stakeholders and communities around Nepal to understand how and why injuries happen, and to develop and evaluate interventions to prevent harm.
“Our programme identified the inequitable and previously unreported burden of injuries for Nepali communities. There are significant opportunities to build on existing legislation, infrastructure and data systems to reduce injury risks and more accurately monitor trends in injuries in the future.”
Professor Julie Mytton, Director of the NIHR Global Health Research Group on Nepal Injury Research
Improving monitoring of road transport injuries to target prevention
Over the last decade, 80,000 km of new roads have been built in Nepal and vehicle numbers have increased by over 800,000. However, many new roads have no proven safety features and are difficult to maintain, contributing to the high rates of injury-related deaths and disability nationwide. The WHO estimates that road traffic deaths in Nepal are more than double those recorded by the traffic police.
In one of several studies investigating road traffic injury prevention, the Group took an alternative approach to monitoring road collisions by engaging local shopkeepers to record traffic crashes in their community. Their study, published in Traffic Injury Prevention, found that only 25% of crashes involving casualties were recorded by police, indicating significant underreporting within formal channels. The Group now works with the police and the civil registration system to strengthen their reporting systems to monitor trends more accurately and inform policy.
Furthering their work on road safety, in 2019 Professors Mytton and Joshi were awarded an NIHR Global Health Policy and Systems Research Development Award to identify road safety research priorities for Nepal using the WHO’s five key pillars for road safety, including road safety management, safer travel, safer road users, safer vehicles and post-crash response. Completion of the study was followed by a workshop with nearly 100 road safety stakeholders to prioritise the research questions it raised. Six of the most urgent topics to inform policies and investment that improve the safety of Nepal’s road system were selected as priorities for funding.
“Hearing each other's views during the priority setting study was an eye-opener for some of the policy makers and road safety stakeholders. I hope that it will help them work together to develop road injury prevention policies in the future.”
Professor Sunil Kumar Joshi, Director of the Nepal Injury Research Centre
Evidence from the Group’s research programme also supported Professor Mytton’s discussion of South East Asian countries’ road safety priorities with the World Bank’s Global Road Safety Facility – a fund that supports research and investment in safer roads around the world. Through the World Bank initiative, jointly funded by the NIHR alongside the UK’s Foreign, Commonwealth and Development Office, road safety barriers introduced on dangerous stretches of open road in Nepal are estimated to have saved more than 3000 lives.
Accurate injury surveillance plays an important role in informing injury prevention programmes and policies but hospital records of patients’ admissions and outcomes from injury were extremely limited. The team carried out hospital surveillance studies in adults (International Journal of Environmental Research and Public Health) and children (Archives of Disease in Childhood) to understand the extent of people’s injuries. They found that injuries among children commonly arose from falls, road traffic incidents and animal bites and stings, and represented areas for injury prevention programmes and policies. Their studies also confirmed that the monitoring systems they trialled could be successfully integrated into government and private hospitals in Nepal.
Care provided by first response services at the scene of an injury is vital to save lives and avoid long-term disability, particularly in LMIC settings where there are no or limited emergency medical services. Published in Frontiers in Public Health, the Group carried out the first thorough report of post-injury first response systems in Nepal, finding that only one-quarter of first responders provided assessment, treatment and transport of the casualty to a health facility. Some responders had received no formal first aid training. Their results suggested that greater coordination and development of services, alongside standardised training of first responders, could markedly improve outcomes for trauma patients.
Injury prevention has been a low priority in Nepal but together with the NIRC, the Group has stressed the need to view injury as a public health problem and highlighted how changes at individual, organisational and governmental levels are needed for the prevention of injuries. The Group has successfully raised the profile of injury prevention by developing a network of academics, decision-makers and advocates, including the Mother and Infant Research Activities, the Nepal Red Cross Society and Swatantrata Abhiyan, a Nepali development and social justice organisation.
This wide network has provided valuable contacts to support engagement with the public and policy makers across a range of Ministries within the Government of Nepal. In 2018 the National Advisory Committee on Injury Prevention and Control was set up, and agencies now work together on the committee to deliver more coordinated and effective injury prevention interventions for the people of Nepal. The Group’s public health expertise and contacts in Nepal have been crucial to establishing the NIRC and, through its support of early career public health researchers, the Centre has a well-qualified and experienced team to continue their injury prevention research.
Reducing death and disability from injuries worldwide
Over the course of the Group’s award the team has also collaborated with other Global Health Research Units and Groups, including on Burns Policy and Prevention Research, Neurotrauma, Road Safety and African Snakebite, and Neglected Tropical Diseases.
NIHR Research and Innovation for Global Health Transformation (RIGHT) funds cutting-edge interdisciplinary applied health research in key areas in LMICs where a strategic and targeted investment can have a major impact. Its fourth and most recent call for research proposals in November 2020 targeted the global burden of unintentional injuries and urgent and emergency care, with the aim of investing in high quality research to address a lack of funding in the important public health issue of unintentional injuries in LMICs. These projects are due to begin in Autumn 2022.
Supported by NIHR’s joint funding, the World Bank Global Road Safety Facility has also provided funding, knowledge and technical assistance to 81 countries to strengthen their road safety interventions and save lives. A vital part of the GRSF mission is the Road Safety Grant Program, which supports the World Bank and other institutions with their road and urban transport investment projects as well as advancing global road safety research.
Road Safety Grants have been awarded to improve pedestrian safety in Ethiopia and improving vehicle inspections to improve safety and reduce pollution in Togo and Cameroon. This investment has helped Togo establish the necessary technical requirements for the import of safer vehicles and assisted Cameroon to identify strategies to make vehicles safer and transport more efficient. A global project to develop an automated road safety scan system has also been developed that detects road characteristics, such as road signs and bike lanes, from street level images and provides a safety prediction to support road safety evaluations.
Reliable safety and traffic data are essential to assess the extent of each country’s road safety problem, measure the economic costs associated with road crashes and design the most cost-effective road safety interventions. To facilitate this the GRSF established a network of Road Safety Observatories – a formal group of government representatives to share and exchange road safety data and experience to reduce traffic injuries across countries in the region. Following the model of the Latin American Observatory, NIHR funding has supported the development of road safety observatories in Africa and Asia Pacific.