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

Abstract

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: To understand the epidemiology of injuries.

To identify potentially modifiable risk factors to inform the development of prevention interventions.

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 Master’s 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, at 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 threefold over 8 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.