You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Developing countries

Quantifying the burden of injury in ‘data-poor’ setting; a local-need- driven approach?

12 Oct, 16 | by Brian Johnston

Editor’s Note: earlier this year the journal published injury data from the Global Burden of Disease project. In an accompanying editorial I noted that many of the regional or sub-national estimates were “derived from aggregation and extrapolation of limited primary sources “and yet could “become the basis for policy or programming at an intensely local level.”

I saw this as a challenge to researchers, a call to “crowd source” burden of disease data from  the subregions and subpopulations unrepresented, or simply estimated, in the global aggregate. If we identified those needs and provided resources for good data collection, data management and data reporting , the information collected would be immediately useful at the global scale and  – one hopes – at the local level too. 

Dr. Safa Abdalla, a member of our editorial board, approaches that suggestion with some caution and – in this guest post – draws distinctions between the needs and experience of researchers and public health professionals in “data-rich” and “data poor” environments. – Brian Johnston (Editor-in-Chief)

 

safa-abdallaSome parts of the world, typically in the low- and middle- income country classification range, lack solid basic information about frequency and distribution of injuries in their population. That is not to say that they lack the sources or the capacity to measure them, but in those same places, the public health practice machinery had been occupied (not entirely unduly of course) with a cluster of conditions like communicable diseases that international actors have been investing heavily to tackle. In such environment, local objective assessments of all potentially impactful conditions may not have been deemed necessary. As a result, priority setting has been skewed towards those conditions of historical focus without heavy reliance on local epidemiological evidence.
The very first global burden of disease and injury assessment and subsequent versions have highlighted the need to consider the burden of all realistically possible conditions that affect human health – including injuries – in a way that allows objective comparisons and consequently objective priority setting. Arguably, data from so called ‘data-poor’ countries had not always been sufficient and/or accessible enough to feed into these global-level estimation projects and data gaps were filled with an assortment of methods that continue to evolve to date, probably at a rate that surpasses the rate of improvement in the quantity and quality of data from those countries.
The burden of disease assessment methodology is very demanding, not only computationally but in terms of data input, requiring epidemiological estimates at the very granular level of disease and injury sequelae, and synthesizing those into a range of novel summary measures (Disability-adjusted life years for example). Yet, incidence, prevalence and mortality of any condition at a broader level are key inputs for country- or locality-level policy development and health service planning and monitoring. It is in measuring those epidemiological quantities that the value of country-level estimation in data-poor settings lies, without necessarily delving into the complexities (and relatively unnecessary luxury for the time-being) of summary measure calculation. In addition, country-level assessments can uncover gaps in data systems that, when addressed, can create a seamless flow of better quality data for local decision making.
But with whom does the onus of carrying out such local-level estimation reside? Undeniably, global estimation efforts have produced country-specific estimates, stimulated country data hunts that fed data into their machinery and, in a few ‘data-rich’ countries, facilitated full burden of disease and injury assessments too. However, to date, injury burden estimates for the vast majority of ‘data-poor’ countries come from indirect estimation in these global projects. One can argue that alternatively, an approach that is driven by the need for public health action (be it strategy updating or service development) would be the most beneficial for producing estimates for those very countries at national, sub-national or subgroup levels. This approach entails that a local team of researchers, public health practitioners and other stakeholders evaluate all their data sources, use them in a simple and transparent fashion to develop the best estimates that fit their purpose, and take action based on the estimates and other relevant input while also identifying the data gaps and working on filling them. Arguably, informing local public health action should take priority over informing the global view, but global burden estimation efforts can still (and must) benefit from the products of this process. However, the process needs to be driven by local demand for estimates and not by the need to fill gaps for the global estimates. It should also be led, undertaken and owned by local teams of public health practitioners, analysts and researchers. The reason for this is that assessing and using health data are basic public health functions that all public health practitioners and analysts in any country should be capable of carrying out. Relying on external support from ‘global project’ teams to develop country estimates denies public health practitioners and researchers in those ‘data-poor’ countries the opportunity to hone their skills in public health data assessments and epidemiological estimation. It also denies them ownership of any subsequent efforts to improve data availability via epidemiological studies or administrative data collection.
This approach need not be limited to injury burden assessment but is much more needed for that latter. This is mainly because injuries in many low- and middle- income countries had been neglected for so long that epidemiological assessments of other conditions traditionally associated with those countries are likely more abundant. Hopefully as more and more country teams assess, use and improve their own injury data sources, this reality will eventually change.

Safa Abdalla
drsafa@yahoo.com
twitter: @Safa12233

Botswana reflections: on learning the ABCs

15 Oct, 15 | by Sheree Bekker

I am currently in Botswana: a landlocked southern-African country of roughly two million people. I grew up here, and it is a place that I consider one of the most beautiful in the world (particularly the Okavango Delta – a bucket list destination for wildlife). The country and its people were beautifully portrayed in this music video from Nico and Vinz (take note Taylor Swift).

Although Botswana is amongst the most economically and politically stable countries in Africa, the need for public health improvements (as with other countries) remains a priority.

The top ten causes of death in Botswana, according to the Centers for Disease Control and Prevention (2010) are:

  1. HIV
  2. Cancer
  3. Stroke
  4. Tuberculosis
  5. Ischemic Heart Disease
  6. Diarrheal Disease
  7. Diabetes
  8. Road Injuries
  9. Lower Respiratory Infections
  10. Malaria

It is no surprise that HIV remains at number one on this list, in 2014 the prevalence of HIV in adults aged 15 to 49 was 25.2% – second in the world only to Swaziland.

The ubiquitous presence of the HIV epidemic can still be seen in the faded remains of the educational messaging that was painted on every available public wall in the 1990s and early 2000s.

SANYO DIGITAL CAMERA

SANYO DIGITAL CAMERA

Indeed, I so clearly remember that we learned our ABCs at school in Botswana, the letters themselves certainly, but almost more importantly the potentially life-saving versions too: A) Abstain, B) Be wise, C) Condomise. To this day, condoms are widely and freely available (useful, except when the HIV awareness ribbons are stapled to – through – the condoms themselves).

Botswana has generated what is often referred to as a ‘stunning achievement‘ in its multi-faceted response to the HIV epidemic. This success means that the government can now allocate resources to start to address other public health concerns.

Number eight on the above list, road injuries, is now seeing an uptick in prevention initiatives. A 2012 abstract published in Injury PreventionCharacteristics of casualty crashes in the Republic of Botswana: identifying evidence-based prevention opportunities showed that:

Fatality rates increased by 383% (per 10 000 vehicles) from 1975–1998, with recent estimates indicating a 50% higher fatality rate per population than the global average.

The Global Burden of Disease 2010 Study showed that alcohol use was the leading risk factor for disease burden in Botswana. A 30% tax on alcohol (reduced from the initial plan for a 70% tax) was subsequently introduced. A second 2012 abstract in Injury PreventionComparing fatal alcohol-related road traffic crashes in Botswana pre- and post-passage of a national alcohol levy showed:

A large percentage of fatal alcohol-related crashes (FARCs) occurred on weekends (49%), among males (78%), and among 25–34 year-olds (35%).

Comparing changes pre- and post-levy, we found that there was a statistically significant change in FARCs per 10 000 registered vehicles (rate pre-levy=10.4; 95% CI 9.1 to 11.8 vs rate post-levy=8.3; 95% CI 7.3 to 9.3; p=0.01). However, rates per 100 000 population remained stable pre- and post-levy (rate pre-levy: 6.9; 95% CI 6.0 to 7.7 vs rate post-levy: 7.5; 95% CI 6.6 to 8.4; p=0.29).

Alcohol is, obviously, only one element of the highly complex issue that is road safety in Botswana. Road safety issues that I notice here daily include: lack of seatbelt use, unrestrained children, unroadworthy vehicles, animals on roads, speeding, negligent driving, potholes, and overcrowded vehicles. It is encouraging to see work being done on the ground to improve safety (police spot licence checks for example), however it will take time and a multifaceted, focused, local strategy similar to that seen in the HIV response for any great strides to be made. Encouragingly, we know that research and policy have had positive impacts in similar countries around the world. Interestingly, Botswana’s current road safety initiatives do not seem to be as creative as the robots in the Democratic Republic of Congo.

Whilst there is much to achieve in Botswana on the issue of road safety, the success of the HIV campaign means that Botswana can be proud of its initiatives to prevent injury to and illness in its citizens and visitors alike.

 

*Please note that I am not a researcher in the area of HIV or road safety, and this blog is largely based on my personal observations and knowledge. I welcome comments and insights from people who are – either below, or on our Twitter or Facebook.

Concern for prehospital care/ambulance services

10 Aug, 15 | by jmagoola

I spent last week travelling in Adjumani district (located in Northern Uganda) as part of an exercise in improving the quality of immunization data through support supervision and mentor-ship. This required us as a team to visit as many of the health facilities in the district as possible. Due to the limited sources of our country, we had to make do with one of the hospital ambulances as a means of transport. In between ferrying us from one health facility to another, the driver would get calls to go pick up emergency cases that required urgent transportation to hospital.

In this scenario, all the ambulance is manned by only a driver (no paramedic, no nurse) whose role is to pick you up and drop you at the nearest health facility. One of 2 ambulanes currently used by the district to transport patients during emergencies.No triage, no first aid, no prehospital care until arrival. This could contribute to the trauma mortality rates, which are already higher in rural areas before victims reach the hospital. It is known that travel time is a predictor of the outcome of an injury and as such many fatal injuries or their severity may be reduced by adequate prehospital trauma care. A previous study in Uganda found that fewer than 5% of injured patients are transported by ambulance to hospital  most of which ambulances are privately run and expensive. In neighboring Tanzania, a study evaluating access to prehospital care found there was no prehospital care in the region.

The interior of the ambulance, lacking paramedic supplies for first aid.

The interior of the ambulance, lacking paramedic supplies for first aid.

This highlights a major need to prioritize the development of prehospital trauma care if we are to address the issue of injuries. In addition, while the presence of an ambulance will reduce the travel time to hospital and thus increase the chance of survival, the ambulances themselves should be equipped with materials to offer some basic first aid during the course of transportation. They key policy and clinical practice questions we should ask ourselves should include; how equipped are the ambulances?; what should be the minimum standards a vehicle should attain before it is designated as an ambulance?

 

More background on our blogging team

19 Jun, 15 | by Bridie Scott-Parker

Blog 3: So today I wanted to share some more background on our blogging team. As an applied social psychologist, I find this information very interesting indeed!

What excites you about being part of the Injury Prevention social media editorial team?  

Sheree Bekker: The invaluable conversation that has sprung up around scholarly work through the collaborative power of social media and blogs inspires me to no end. I tend to find more relevant scholarly content through Twitter than through traditional platforms, and Injury Prevention has played a big part in that. As researchers, I believe that we should own our voice on social media, and constructively add value to this conversation.

David Bui: Through my studies in medical school I have seen the costs of injuries to society and individuals worldwide.  This is a great opportunity to harness the underutilised power of Social Media in health promotion and Injury Prevention, across multiple disciplines and multiple borders.

Angy El-Khatib: Being a part of the Injury Prevention social media editorial team is a great opportunity personally and collectively. By being a part of the social media editorial team, I am able to stay up to date on various topics within the realm of Injury Prevention while acquiring different perspectives from individuals from different backgrounds, disciplines, and locations. I’m also excited to be able to potentially increase readership and engage readers to create a conversation around the latest Injury Prevention research and ideas.

Klara Johansson: I am very interested to explore ways to share and disseminate knowledge and research results, outside the “old-school”, regular channels. I look forward to learning from my new co-editors, who all seem to be great communicators.

Joseph Magoola: The opportunity to work and collaborate with a variety of scholars on the injury prevention platform is nothing short of exciting. It also excites and inspires me to have an opportunity to represent Africa since low and medium income countries bear the brunt of the injury burden.

Julian Santaella-Tenorio: It is really exciting to be part of this team and to have a space to communicate and express ideas on ways to improve injury prevention, and to discuss about new studies and topics relevant to this field. I am very motivated to learn more and continue growing as a researcher as I walk through this experience.

What are you passionate about?

Sheree Bekker: Intersectional issues drive my life’s work, and my aim is that my research is, and always will be, an extension of that.

David Bui: Passionate about bringing people and ideas together.

Angy El-Khatib: I am passionate about translating scientific evidence and research into public health action. My goal is to improve the health and wellbeing of myself as well as my community. Outside of my work, I am passionate about health, fitness, and wellness.

Klara Johansson: Open discussions and innovative research in collaborative teams with high scientific ambition + high levels of tolerance and kindness; I also enjoy making difficult subjects understandable to students and the general population. Passions on my free time: nature, gardening, books, movies, writing fiction, playing music (clarinet, harmonium, piano, accordion).

Joseph Magoola: Writing on my social media accounts (facebook, twitter and my blog) as a way of reaching out to the masses. I am also interested travelling a lot, especially by road and as such, ensuring road safety is part and parcel of my aims to contribute towards reducing the carnage of our roads.

Julian Santaella-Tenorio: I am passionate about things that can make people have a better, healthier and happier life. I am inspired by ideas challenging previous knowledge, creative thinking finding answers from different angles, and the power of multidisciplinary groups. That is why I am passionate about public health research.

 

I hope you are looking forward to hearing from our bloggers, starting next month!

World Health Day 2015

7 Apr, 15 | by Bridie Scott-Parker

In case you didn’t know, today, the 7th of April, is World Health Day 2015. As can be read on the World Health Organization website, WHO hopes to highlight

the challenges and opportunities associated with food safety under the slogan “From farm to plate, make food safe.”

“Food production has been industrialized and its trade and distribution have been globalized,” says WHO Director-General Dr Margaret Chan. “These changes introduce multiple new opportunities for food to become contaminated with harmful bacteria, viruses, parasites, or chemicals.”

Dr Chan adds: “A local food safety problem can rapidly become an international emergency. Investigation of an outbreak of foodborne disease is vastly more complicated when a single plate or package of food contains ingredients from multiple countries.”

My husband experienced first hand the consequences of poor food handling practices, experiencing severe gastrointestinal upset which started showing itself half way through a 16-hour cross-Pacific flight. The extremely unpleasant side-effects lasted for several days, and he will not be eating airport lounge fast-food any time soon!

I myself had a number of blood tests earlier this year after persistent ill health – thankfully I returned negative results, unlike other Australians who similarly had eaten contaminated berries imported from overseas. This latest scare has prompted a call for clearer packaging, and improved safety standards in Australia and overseas.

Our immediate experiences cannot compare with those of individuals who have lost their lives due to foodborne illnesses, however. The WHO has released its preliminary findings regarding the global burden of foodborne diseases, with additional findings expected later this year. I look forward to seeing further results in this important injury prevention domain.

 

 

Mentor VIP

9 Feb, 15 | by Barry Pless

I received this email from David Meddings. This excellent program seeks volunteers. Do consider doing so.

Dear MENTOR-VIP participants (past and present),

Applications for the ninth cycle of MENTOR-VIP are now open. This means individuals wishing to apply to be mentored during 2015-2016 may make their applications via our website (link given below) between now and May 8.

As you know, MENTOR-VIP is designed to assist junior injury practitioners develop specific skills through structured collaboration with a more experienced person who has volunteered to act as a mentor. The programme provides a mechanism to match demand for technical guidance from some people with offers received from others to provide technical support.

Mentoring arrangements may take place in whatever language or languages the mentor and mentee are comfortable to communicate in. The majority of interaction between mentor and mentee takes place through low cost electronic communication such as email, internet-based telephony, or telephonic exchange.

I would appreciate if all of you could take steps within your own communications to make people aware that the programme is now accepting applications. The main message for potential candidates is that applicants who wish to apply for one of the available positions must do so by the application deadline of May 8 through the capacity building section of WHO Headquarter’s website for injury and violence prevention.

All applications to the programme are made online and more detailed information is available at http://www.who.int/violence_injury_prevention/capacitybuilding/mentor_vip/.

Please feel free to forward this email within your networks and do let me know if you have any questions.

Best wishes,

David Meddings

Applications for MENTOR-VIP are now open
Do you work in the injury and violence field and want to improve your skills?
MENTOR-VIP is a global mentoring programme for injury and violence prevention developed by WHO and a global network of experts. Applications for mentees to be mentored during the 2015-2016 period are now open through May 8, 2015.
To find out more, or to submit your application to be mentored please go to:
http://www.who.int/violence_injury_prevention/capacitybuilding/mentor_vip/Mento

Proactive rather than ‘The Hindenburg’ response

3 Feb, 14 | by Bridie Scott-Parker

I had a conversation recently with a colleague who is a tireless worker in the safety of pedestrians, and his comment regarding policy response resonated with me so much that I thought I would share it with you. He likened policy response to road safety to the Hindenburg Disaster of 1937 (see www.airships.net/hindenburge/disaster for more information), such that improvements in safety only occur after tragic, highly-visible critical events. This policy response, which certainly is an important one, is frequently characterised by ‘too little, too late’. My colleague found this particularly frustrating when policy based in sound risk assessments and a plethora of evidence-based research can prevent – or at least minimise – the damage from catastrophe in the first place.

Whilst myself and my colleague are lucky enough to live, work, and indeed use the road environment in a developed country, evidence-based policy and practical responses are never more urgently needed than now in developing countries. The plight of these countries was highlighted in a recent The Economist article (read more at http://www.economist.com/news/international/21595031-rich-countries-have-cut-deaths-and-injuries-caused-crashes-toll-growing). What we in ‘rich countries’ refer to as vulnerable road users such as pedestrians and motor and pedal cyclists are never more vulnerable than when using the road networks of the developing world.

Interestingly, cost cannot be the only obstacle, with The Economist article stating that

iRAP has helped to build fences to separate pedestrians from traffic in Bangladesh, at a cost of just $135 to avert a death or serious injury; and installed rumble strips on hard shoulders in Mexico to alert drivers when they are veering from their lane ($920). Telling people about safety laws—and then making those laws stick—can be surprisingly affordable and effective, too. The share of people wearing seat belts in Ivanovo, Russia, rose from 48% in 2011 to 74% in 2012, after a police crackdown and social-media campaign partly paid for by Bloomberg Philanthropies, the foundation of Michael Bloomberg, New York’s former mayor and one of the few big aid donors to spend heavily on road safety. Dan Chisholm of the WHO calculates that enforcing speed limits and drunk-driving laws in South-East Asia would cost just 18 cents per person per year.”

I would argue that a part of our role as injury prevention practitioners, professionals and researchers in ‘rich countries’ is to help in the journey to identify, then remove or ameliorate, obstacles to developing nations maximising the benefits of our knowledge and experiences.

E-bikes and injury prevention

20 Oct, 13 | by Bridie Scott-Parker

The ever-problematic struggle between mobility and safety is not exclusive to motorised jurisdictions such as Australia or the United States. Indeed emerging evidence suggests that developing nations are particularly vulnerable as they struggle to develop, implement and enforce road rule strategies to minimise risks to safety whilst maximising the nation’s mobility. Whilst worldwide the demand for E-bikes (whether they feature pedals or resemble scooters) rises, China currently accounts for 90% of the global market.

In China, E-bikes are considered to be a non-motorised vehicle, and riders are not required to wear helmets. A recent observational study of of over 18,000 E-bike rider on-road behaviour, including observation of any safety equipment worn by E-bike riders, found that:

* 26.6% of riders violated road rules, for example 12.4% carried passengers, 4.8% were observed to ride through red lights and 3.4% rode against the traffic direction, suggesting a need for both education and enforcement initiatives; and

* 41.1% of riders were observed to wear at least one item of protective gear (mainly gloves) however only 9.0% were observed to wear a helmet, suggesting the need to introduce mandatory legislation supported by evidence that helmets reduce both the incidence and severity of injury, in addition to education regarding the importance of protective gear for two-wheeler riders in particular.

In addition, the Authors note the potential for E-bikes to be legislated as motorised vehicles, notwithstanding the contentious nature of this debate. Read more at http://www.ncbi.nlm.nih.gov/pubmed/23877004

A cell phone app for training road safety skills to Kenyan motorcycle-taxi drivers

23 Jul, 13 | by Junaid Bhatti

Commuters in developing countries often have few choices when it comes to safe travel. The combination of high fuel costs, scarcity of standard vehicles, and inadequate road networks lead to alternative means of transport, which are not necessarily the safest. An example of this is the sprouting of the motorcycle taxis or “Borda-Borda” in Kenyan’s urban and rural areas. Commuters are attracted to this “low-cost” travel. The Kenyan government has also supported the “Borda-Borda” movement as it indirectly helps reduce unemployment. Recent reports indicate that the growing motorcycle-taxi phenomenon is dangerous. Travelling on these taxis is risky as they are mostly driven by young men, not adequately trained or licensed to operate these motorcycle-taxis. Crashes can lead to severely incapacitating injuries for the taxi drivers and passengers. Kenyan experts agree that some part of the recent increase in the Kenyan road mortality is attributable to increased motorcycle use in the country.

Traffic enforcement can be an effective option to align “Borda-Borda” drivers with safety standards however, resources are often limited in low-income countries like Kenya to increase implementation of such initiatives beyond major cities. Therefore, innovative solutions are required to increase the adoption of safety practices. A Kenyan NGO El-Friezo is currently piloting an interactive cell phone application (app) to improve the road safety skills of Kenyan motorcycle-taxi drivers.

Link to website: http://www.guardian.co.uk/global-development/2013/may/13/kenya-mobile-app-motorbike-roads

According the a NGO spokesperson, this app is an innovative training tool that uses a series of games to train drivers about motorcycle safety. It also includes exercises for providing first aid at a crash scene. These exercises were developed in collaboration with the Kenyan Red Cross. This initiative includes a built-in evaluation strategy as the app also collects data on road safety.  El-Friezo is counting on the current widespread use of cell phone in Kenya. Funded by the Grand Challenges CanadaTM and supported by the Keyan AirTel, the NGO has started recruiting 1,000 drivers in two Kenyan cities located in the Rift valley. El-Friezo is hoping that, in the near future, use of this app will play a significant part in driver training nationally and in other African countries facing the same problem.

Editor: In my opinion, the use of cell phone technology in road safety skill training is worth a shot though some colleagues may find this controversial as cell phone use while driving is associated with increased crash risks. Cell phones are fast becoming part of everyday life in the low-income countries. Proposing to use this technology in providing individualized road safety skill training is innovative and can be safe if adequately monitored. It is also nice that this project has captured the imagination of well-known international funding competition, the Grand Challenges (link to project: http://www.grandchallenges.ca/grantee-stars/0239-01/).

Acknowledgement: G. Tung.

Malnutrition: Another form of injury that can be prevented

30 May, 13 | by Bridie Scott-Parker

This week my attention was drawn to the Save the Children’s report “Food for Thought: Tackling child malnutrition to unlock potential and boost prosperity” (read more at http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/FOOD_FOR_THOUGHT.PDF).

As I read this report, I had to reassess exactly what I believed injury to be.

The most basic definition of injury is damage or harm which is inflicted upon or suffered by a person. There is no doubt in my mind that malnutrition is another form of injury.

Perhaps one of the reasons malnutrition has not been comprehensively examined in the peer-reviewed publications such as Injury Prevention is that the impact of the injury may not be felt for many years. The short-term impact of malnutrition is widely recognised, with one child dying every 15 seconds. The long-term impact of malnutrition is not as widely recognised, the Food for Thought report highlighting the long-term effects of infant and child malnutrition in poor literacy and numeracy at school, which directly impacts upon the the adult’s ability to earn.

As injury and injury prevention researchers, practitioners and policy makers, we strive to understand the factors contributing to or causing the injury, how we can prevent and minimise any damage or harm from that injury, and we shape policy and practice at every opportunity to better the lives of all. The peer-reviewed literature constantly documents the increased vulnerability to, and greater impact felt by, persons from lower socioeconomic environments for a range of injuries. It seems to me that malnourishment requires greater injury prevention efforts. Simple direct nutrtition interventions, such as iron and iodine supplements, can not only ameliorate the symptoms of malnutrition but can also reduce healthcare costs.

Latest from Injury Prevention

Latest from Injury Prevention