1A1. Introduction

With a population of more than a billion, India is

facing many challenges to meet health needs of its

people. The triple epidemics of Communicable and

infectious diseases, Noncommunicable diseases

(NCDs) and injuries pose many challenges for health

systems and to our policy makers. Various policies

and programs by successive governments at both

central and state level have had some success in

changing some vital indicators. Despite this

noticeable change, the consequences of globalisation,

urbanization and motorization have emerged as

major challenges amidst existing social inequities

and wide disparities in health systems between and

within states. Absence of efficient health systems as

revealed by the inadequacies related to planning,

financing, human resources, infrastructure, supply

systems, governance, information, and monitoring

are some well known problems of our health care

systems (Patel et al, 2011).

India has witnessed rapid and unprecedented changes

in urbanization, motorization, industrialization and

migration along with changing life styles, habits

and value systems of people. The ongoing

epidemiological, demographic, economic and social

transition has resulted in the emergence of injury

and violence as a major public health problem in

the 21st century. India has been making small and

significant progress in NCD prevention and control

programs along with expansion of trauma care

services. The augmentation of facilities and services,

though marked in urban areas and deficient in rural

areas, has been receiving attention of policy makers

and administrators. In recent years, increasing

participation of the private health sector comprising

of specialty hospitals, corporate hospitals, teaching

hospitals, nursing homes and other family

practitioners along with the public health sector has

been noticeable. Simultaneously, increasing costs of

health care, greater burden on individuals and

families, and the limited and adverse impact of

various policies and problems has also been a matter

of great concern.

Recent data indicates that NCDs and injuries

contribute for nearly three fourths of deaths and

disabilities in India (Patel et al, 2011). Even though

recent years have witnessed some concerns from

policy makers on the growing incidence and burden

of injuries, the problem has not received major

attention in terms of a unified approach to address

the problem. While some of the recent programs

are making systematic efforts to address the growing

burden of NCDs, efforts for injury prevention and

control are totally lacking as they are not even

recognized as public health problems in India.

Section A:

Injury and Violence in India

2 BRSIPP 2011

A2. Scientific basis of injuries

Traditionally and for too long, injuries have been

considered as accidents. The term accident simply

means that it just happens and nothing much can be

done about it. Consequently and for a long time, the

fatalistic attitudes in our communities have persisted

and continue even today. Injuries have been referred

to as - acts of God, sins of past life, price one has to

pay, and several such understandings. Due to this

prevailing thinking by politicians, people and even

professionals, the field of injury prevention and

control has not taken deeper grounding in India.

The epidemiological triad of agent, host and

environment has been in practice for several

years that evolved from the understanding of

communicable disease control. Haddon Matrix

is a very scientific method to understand injury

mechanisms at different time periods and at various

levels (Haddon, 1968). This concept that originated

in 1970s brought in a new understanding of injury

mechanisms by identifying the contributory factors

among people, vehicles or products, and the

environment (Table 1). Within each of these three

domains, factors that operate before, during or after

the crash that influence the possible outcomes can be

delineated. Identifying and developing mechanisms

to address each of these for different injuries has helped

in reducing RTIs and other injuries.

In recent years, the Safe Systems approach is an

extension of this model by identifying measures for

safe people, safe vehicles and safe roads for prevention

and control of RTIs. This approach considers different

interactions between and within each component and

is based on physiological tolerance of individuals. It

is based on the understanding that human body is

extremely vulnerable for injury and that people are

likely to make mistakes. Hence, road crashes are the

outcomes of different interactions among a number

of factors and interactions. Based on this

understanding it is essential to address multiple

components that cause injuries by different partners

(Mohan et al, 2006). This approach focusses on

Safe people, Safe roads and Safe vehicles. This

understanding has revolutionized the field of Road

safety as well as injury prevention and control over

time and it has been possible to identify injury

prevention programs that can be effectively

implemented.

Human Vehicle Environment

Pre-event Increaseawareness

about helmetwearing, drink

driving, safe

driving, etc.

Increase

visibility of

vehicle

Implement

safety features

on roads

Event Early transferto hospital

and requiredcare

Better braking

systems of two

wheelers

Crash

protective

road sidestationary

objects

Post-event

Rehabilitateand improve

health care

services

Improve safetytechnologies

and compo-

nents

Facilities forearly rescue

of injured

persons

Table 1: Example of Haddons matrix asapplied to two wheeler road traffic injury

A3. Injury and violence as a public health

problem in India

Commonly, injuries are classified as unintentional and

intentional based on intent. Unintentional injuries

include Road Traffic Injuries (RTIs), falls, burns,

poisoning, drowning, work related injuries, fall of

objects, injuries in disasters and animal bites.

Intentional injuries include suicides and violence.

Violence includes a wide variety of conditions like

youth violence, violence against women, children and

elderly, communal violence and those occurring in

custodial institutions. Another method of classifying

injuries is based on the mechanism of injury as it

happens in road traffic injuries, poisoning, falls and

others. The third method of classification is based on

the place of occurrence like roads, home, play sites

or work places. The anatomical type and location of

injuries depending on the injured body organs like

head injuries, intracranial injuries, fractures and

dislocations are the fourth method of classification.

3Several international frame works like the WHO

international classification of diseases (WHO, 1998),

International Classification of External Causes of

Injuries (WHO, 2004a), and the International

Classification of Functional Impairments are available

for more detailed understanding of injury process and

mechanisms (WHO, 2001a).

It is common to see, read, hear or witness injury

deaths and events in our lives on a day to day basis.

Like any health condition, injury and violence also

has the typical epidemiological understanding of

agent (product), host (person) and environmental

association. The term, injury, by definition means

that it is a body lesion due to an external cause,

either intentional or unintentional, resulting from a

sudden exposure to energy through mechanical,

electrical, thermal, chemical or radiate sources that

is generated due to interaction between agent and

host (WHO, 1999). This definition has been

expanded to include impairments and others. The

interaction of these elements results in transfer of

energy to the host, which when it exceeds the

physiological tolerance of the individual results in

damage to body organs. Depending on the product,

the energy that is responsible can be mechanical (as

in RTIs), chemical (as in poisoning), thermal

(burns), electrical or radiant in nature. It is also

possible that injuries can occur due to sudden

withdrawal of a vital requirement of the body as in

drowning due to lack of oxygen.

The understanding that injury is damage to one or

more body organs, which occur quite rapidly due

to sudden energy transfer being the cause,

revolutionized the science of injury prevention and

control. The definitive interaction between agent,

host and environment along with energy transfer

results in injuries of varying nature and severity. The

chances of repeated occurrence are also frequent.

Over time, moving from this concept, the safe

systems approach has evolved for prevention and

control.

Any health problem is a public health problem, if it

affects large sections of society, has identifiable and

measurable risk factors, is amenable to prevention

and can be addressed through public health

approaches (Detels et al, 2009). Due to lack of good

quality data on the burden, pattern and impact of

injuries, the problem remains unrecognized and

consequently unaddressed in India. However, the

death of nearly 5,00,000 persons as per official

reports every year indicates the enormous

magnitude of the problem. Injuries predominantly

affect the young people in the society, primarily in

the age group of 15-44 years and men, with majority

belonging to lower and middle income strata of the

society. International research and experience reveals

that the risk factors of injuries are clearly discernable

and are amenable for prevention as seen by a decline

in injury deaths and disabilities in recent decades in

many High Income Countries (HICs)(WHO, 2004b).

A4. Burden of injury and violence in India

The only major source of information on injury and

violence in India is the National Crime Records

Bureau (NCRB) under the Ministry of Home Affairs,

Government of India. NCRB publishes annually

Accidental deaths & Suicides in India and Crime in

India.The reports of 2009, published in 2010, gives

salient findings on injury burden and patterns from

different states, union territories and the mega cities

of India (NCRB, 2009a & b). Despite limitations of

reporting and timely publication, the report offers

valuable insights into the current situation of injury

and violence. Some of the salient observations are

also provided in the accompanying report entitled

Injury and violence in India: facts and figures

(Gururaj, 2011).

In 2009, there were 4,76,576 accidental deaths in

the country due to manmade causes (Table 2).

A total of 6,47,904 unnatural accidents caused

4,76,576 deaths and injuries among 1.5 million

persons with a male to female ratio of 3: 1. A 4.3%

increase in accidental deaths has been reported, while

a 7.2% decrease was noticed from deaths due to

natural causes. Significant variations exist across

the states due to population characteristics and levels

of motorisation and urbanisation.

The major unnatural cause of death was road traffic

injuries, which resulted in death of 1, 26,876 persons

in 2009. The share of accidents due to natural

causes decreased from 7% in 2008 to 6.2% in 2009.

4 BRSIPP 2011

Table 2 : Deaths and injuries in India, Karnataka state and Bangalore city due tovarious causes, 2009

A Unintentional injuries

I Air-Crash 0 0 0 1 0 12

II Collapse of Structure (Total) 0 9 9 282 556 2847

1 House 0 0 8 146 242 1091

2 Building 0 1 1 17 47 265

3 Dam 0 0 0 0 15 30

4 Bridge 0 0 0 0 32 44

5 Others 0 8 0 119 220 1417

III Drowning (Total) 5 43 6 2014 553 25911

1 Boat Capsize 0 0 0 51 33 984

2 Other Cases 5 43 6 1963 520 24927

IV Electrocution 4 29 11 365 453 8539

V Explosion (Total) 1 4 3 9 735 668

1 Bomb Explosion 0 0 0 0 491 261

2 Others (Boilers, Gas Cyld. etc.) 1 4 3 9 244 407

VI Fall (Total) 7 108 14 470 2416 10622

1 From Height 3 100 10 442 959 8796

2 Into Pit/Manhole 4 8 4 28 1457 1826

VII Factory 0 2 4 33 598 1467

1 Machine Accidents 0 2 4 32 552 1044

2 Mines or Quarry Disaster 0 0 0 1 46 423

VIII Fire (Total) 32 449 55 1625 3034 23268

1 Fireworks/Crackers 0 11 0 12 258 547

2 Short-Circuit 0 19 2 126 207 1328

3 Cooking Gas Cylinder/Stove Burst 13 89 34 341 241 4127

4 Other Fire Accidents 19 330 19 1146 2328 17266

IX Fire-Arms 0 15 0 18 671 1504

X Killed by Animals 1 1 5 50 198 962

XII Poisoning (Total) 20 388 25 2491 5269 26634

1 Food/Accidental intake of Insect. etc. 0 57 5 181 1662 8154

2 Spurious/Poisonous liquor 2 22 2 180 109 1450

3 Leakage of gases etc. 0 0 0 13 10 247

4 Snake Bite/Animal Bite 1 2 1 722 1900 8035

5 Other 17 307 17 1395 1588 8748

XIII Stampede 6 0 6 12 6 110

XIV Traffic Accidents (Total) 5705 742 61697 10163 470941 152689

1 Road Accidents 5705 742 61697 8714 466649 126896

2 Rail-Road Accidents 0 0 0 0 477 1516

3 Other Railway Accidents 0 0 0 1449 3815 24277

XV Other Causes 74 676 78 1022 4500 35906

XVI Causes Not Known 63 0 66 1125 1389 17534

Total of unintentional injuries 5918 2466 61979 19680 491319 308673

B Intentional Injuries

XVII Intentional Injury Deaths

1 Homicides 0 256 0 1702 0 32369

2 Dowry deaths 0 50 0 264 0 8383

3 Suicides 0 2167 0 12195 0 127151

XVIII Other Intentional Injuries

1 Attempt to commit murder 338 0 1607 0 29038 0

2 Rape 65 0 509 0 21397 0

3 Kidnapping and abduction 270 0 892 0 33860 0

4 Molestation 251 0 2186 0 38711 0

5 Sexual harassment 35 0 64 0 11009 0

6 Cruelty by husband and relatives 367 0 3185 0 89546 0

7 Other IPC crimes 9992 0 61108 0 865541 0

Total of intentional injuries 11318 2473 69551 14161 1089102 167903

Grand Total (A+B) 17236 4939 131530 33841 1580421 476576

Sl. No CausesInjured Killed

Bangalore

Injured Killed

Karnataka

Injured Killed

India

Source: NCRB report, 2009a & b

5Under the broad category of traffic accidents,

4,21,628 road accidents, 2080 rail-road accidents

and 27,575 other railway accidents were reported.

RTIs and suicides were the major causes

contributing for 31% & 27% respectively. (Figure1).

The report highlights an increase of road crashes

in the country by 7.3% during 2009 compared to

2008. Tamil Nadu reported highest rate of road

accidents contributing for nearly 21% of the

national total (Figure 2). Road accidents in India

increased by 1.4% during 2009 as comared to 2008.

In total, 4,15,855 road accidents were reported,

that resulted in death of 1,26,896 persons with an

accident severity index of 30%. The annual

mortality rate was 10.9/1,00,000 population. The

four states of Tamil nadu, Maharashtra, Karnataka

and Kerala accounted for 47% of total road

accidents. The 32 mega cities contributed for 14%

of total road deaths.

In the same year, several more died due to other

injury causes as shown in Figure 1. Nearly 1,27,151

persons ended their lives voluntarily in suicidal acts,

while 26,634 died due to accidental poisoning and

23,268 due to burns. The data also shows the huge

extent of underreporting of injuries in official reports

as seen by the fact that injuries were less than deaths.

As deaths are only the tip of iceberg, for every death,

nearly 30 50 reach hospitals and it is estimated

that the actual number of hospitalised persons are

likely to be in the range of 30 40 million every

year (Gururaj G, 2005a).

In 2009, 1,27,151 persons ended their lives in a

suicidal act. The five states of West Bengal (11.5%),

Andhra Pradesh (11.4%), Tamil Nadu (11.3%),

Maharashtra (11.2%) and Karnataka (9.6%),

contributed for more than half of suicides in the

country (Figure 3). The five southern states registered

40% of total suicides in the country. The four cities

of Bangalore (2,167), Chennai (1,412), Delhi

(1,215), and Mumbai (1,051) together reported

nearly 44% of total suicides among the 35 mega

cities of the country. Bangalore city had the highest

rate: 38.1 per 1,00,000 population. In the total series,

1 out of every 3 suicides occurred in the age group

of 15-44 years with an overall male to female ratio

of 2:1. However, in young children less than 14 years,

male to female ratio was almost equal. One out of

every 5 suicides was registered among housewives.

The age sex distribution of the affected populations

varied across the country. As per the national report,

majority of the deaths due to injuries were in the

State Rate

Tamil Nadu 20.48

Haryana 20.07

Goa 19.17

Andhra Pradesh 17.43

Himachal Pradesh 16.77

Karnataka 14.97

Sikkim 14.50

Rajasthan 13.69

Chhattisgarh 13.07

Gujarat 12.04

Maharashtra 11.99

Delhi 11.80

Madhya Pradesh 11.34

Kerala 11.04

Arunachal Pradesh 10.25

State Rate

Jammu and Kashmir 9.07

Punjab 8.87

Uttarakhand 8.80

Orissa 8.78

Uttar Pradesh 7.58

Meghalaya 7.48

Jharkhand 6.63

Assam 6.50

Tripura 6.41

Mizoram 6.30

West Bengal 5.62

Manipur 4.68

Bihar 4.60

Nagaland 2.25

Figure 2: State wise distribution of RTIs in India, 2009

(National average 10.9/100,000 population)

Figure1: Causes of injury deaths in India in 2009

6 BRSIPP 2011

younger age groups of the population. Nearly 6.5%

of deaths were in children less than 14 years and

majority of deaths were in the age group 15-44 years.

Data from the million death study identified

unintentional and intentional injuries as a leading

cause of death in younger age groups (RGI, 2009).

Most importantly, unintentional injuries were the

4th leading cause of death in 1 to 4 years, while it

was the number one cause of death in 15-24 years

with 11.8% and 15.6% for the two groups of

State Rate

Sikkim 39.9

Kerala 25.3

Chhattisgarh 24.4

Tamil nadu 21.5

Karnataka 21.0

Tripura 20.7

Andhra pradesh 17.4

Goa 16.4

West Bengal 16.4

Maharashtra 13.2

Madhya Pradesh 12.9

Orissa 10.8

Gujarat 10.7

Haryana 10.3

Assam 9.7

State Rate

Arunachal Pradesh 9.0

Himachal Pradesh 8.4

Delhi 8.3

Rajasthan 7.7

Mizoram 6.9

Meghalaya 4.3

Jharkhand 3.6

Uttarakhand 3.5

Punjab 3.1

Jammu and Kashmir 2.5

Uttar Pradesh 2.1

Nagaland 1.4

Bihar 1.1

Manipur 1.0

Figure 3: State wise distribution of suicides in India, 2009

National average - 10.9/100,000 population

unintentional injuries and intentional self harm.

Injuries were the leading cause of death in the 5 - 14

years age group. In total, motor vehicle injuries

contributed to 3.7% of deaths in 5-14 years and 6.9%

in 15-24 years. Injuries were the 8th and the 9th cause

of death in 25-69 years of age group. The top 3 causes

of death in 15-24 years were due to other unintentional

injuries (14.7%), intentional self harm (14.3%), and

motor vehicle accidents to the extent of 12.4%. Injuries

were one among the top 10 leading causes of deaths

in all the groups as shown in tables 3, 4 and 5.

A5. Burden of injury and violence in Karnataka

Karnataka with a population of 66 million is one of

the most progressive states in India. The state with a

motor vehicle population of 3.69 million is

predominantly rural with an urbanization rate of

37% (http://www.municipaladmn.gov.in/

dmaWebsite/urbanization.htm). With literacy rate

of 66.7% and per capita income of Rs 40,998(RBI,

2010), the state is an evolving knowledge and

industrial hub of the country.

During 2009, 33,481 persons (19,680 accidental and

12,195 suicidal deaths) died due to injury and

violence in the state (Figure 4). Among the major

causes, road traffic crashes (8714) and suicides

(12,195) topped the list, respectively. Among other

causes for injury deaths, 2491 were due to poisoning

and 2014 due to drowning. Intentional injury causes

like homicide and dowry resulted in 1702 and 264,

deaths respectively. In the same year, 1,31,350

Figure 4: Causes of injury deaths in Karnataka in

2009

persons were injured as per police reports giving a

ratio of nearly 1:8 for deaths injuries. Considering

underreporting of injuries, the number hospitalized

could have both 1 1.2 million during the year.

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Dandhona et al (2008) reported from Hyderabad

that the RTI mortality rate was 38 / 1,00,000

population, much higher than officially reported

figures. The ratio of deaths: critically injured: mild

injuries was 1: 29: 65 among the surveyed villages

of Haryana. NIMHANS study on suicides showed the

ratio of completed: attempted: suicidal ideations was

1: 10: 100 based on data from hospitals and general

population survey (Gururaj et al, 2004). Sanghvi

et al (2009) reported the number of deaths due to

burns to be 1,63,000 based on estimates, while the

official reported deaths were 22,000 in the same

year.

Reflecting on the data further, it is observed that

national reports provide gross numbers & trend data

with additional information on age and gender, urban

and rural, month and time, sociodemographic

correlates like education and occupation and broad

causes for RTIs and suicides. Further, data is not readily

available for researchers & policy analysts in the public

domain for analysis & interpretation. This data is

supplemented further with few research studies from

different parts of the country on different injury causes.

In summary, comprehensive data required for policies

and programs is not available in the country. It is

time that national institutions like Department of

Health Research (ICMR) and health professionals take

keen interest in developing good quality national level

data on injuries through a combination of quantitative

and qualitative research methods. There is also need

for information from other disciplines like engineering,

transport, industry, law and other sources on different

aspects of injuries. Information from all sources needs

to be available to examine different aspects and to

provide inputs for policies and programs.

A6. Data limitations

A7. Data requirements for road safety and

injury prevention

Unlike communicable disease programs, there is

need for variety of data for road safety and injury

prevention. Primarily, good quality reliable and

comprehensive data is required for policy makers

and professionals to develop meaningful and evidence

based policies/programs and interventions. As per

WHO (WHO, 2010a) reliable and accurate data can

help build political will to prioritise road safety by:

documenting the nature and magnitude of theroad traffic injury problem;

demonstrating the effectiveness of interventionsthat prevent crashes and injuries;

providing information on reductions in socio-economic costs that can be achieved through

effective prevention.

Informative and good road crash data systems should

provide information on (Figure 5)

Figure 5: Use of data for public health and safesystem approaches

Set targetsand monitor

performanceFormulatestrategy

Identify riskfactors,priorities

Defineproblems

11

Magnitude of the problem in terms of deaths,hospitalisations, disabilities and impact

Characteristics of vehicle, the road user andthe road/environment

Situation context and circumstances of roadcrashes

Risk factor identification for selection ofcountermeasures

Effectiveness of interventions in terms ofreduction and changes in the burden, and

Provide reliable output in a timely manner tofacilitate evidence-based decisions.

Using variety of data from different sources,

indicators can be developed to measure progress

in many areas of burden, characteristics and

impact. At each level, different data is required

and this has to be obtained from different sources

by varied methods. A comprehensive road safety

data system would therefore encompass data

collection and analysis mechanisms that cover -

deaths and serious injuries to road users,

characteristics of the crashes; exposure information:

speed, seat-belt and helmet use rates, drink driving,

and vehicle and infrastructure safety ratings; and

impact data in terms of socioeconomic costs to the

society. As discussed in the earlier sections of

this report, such data is not readily available in

India.

A8. Injury surveillance

1. Identifystakeholders

2. Define systemobjectives

3. Define a case

5. Assess availableresources

6. Inform and involvestakeholders

7. Definedata needs

8. Collect data

9. Establish a dataprocessing system

10. Design anddistribute reports

11. Train staff andactivate system

12. Monitor andevaluate

Source: WHO, 2001b

Figure 6: Designing and building asurveillance system

Strong and robust data is an essential prerequisite

to formulate effective road safety and injury

prevention programs (WHO, 2010a). Information is

required on the number of fatal and non fatal injuries,

characteristics of the affected people, the place and

time of injury occurrence, the various contributing

risk factors and causes, trauma care details and

other aspects. This type of comprehensive

information and its availability and utilization will

support development and implementation of policies

and programs.

Surveillance is a very familiar concept in public

health research and refers to ongoing, continuous

and systematic collection, analysis, interpretation,

dissemination, utilization and feed back of data for

reducing the burden of any public health problem

(WHO, 2001b). A similar approach has been used

for injury prevention and control as well in many

HICs. It includes gathering information on individual

cases or assembling information from different

sources, analysing and interpreting information,

dissemination and providing feed back into

programs (Figure 6). It is essential to note that

surveillance is a continuous activity with an inbuilt

feedback mechanism and an action component.

Surveillance helps in recognizing the existing and

changing burden of injuries, understanding various

patterns, identifying new emerging problems,

prioritizing issues and provides a situation analysis

of the current scenario. The data from surveillance

programs needs to be essentially used for

prioritization of issues, capacity strengthening and

human resource development, identifying areas for

interventions, and monitoring and evaluation of

activities. Road safety and injury surveillance data

4. Identifydata sources

12 BRSIPP 2011

can be a meaningful input to several programs and

activities of different ministries, government

departments, health professionals and all others

involved in these activities. It is extremely important

to realize that surveillance moves beyond just data

collection to actually using data for policies and

programs(WHO, 2001b). Further, it is also essential

to understand that surveillance alone will not be

an answer and needs to be supplemented with

variety of different data to pinpoint selection of

interventions. In India, due to absence of central

coordinating agency and data not being valued, most

of the surveillance data remains underutilized, even

in Communicable Diseases surveillance activities.

Many, including professionals believe that RTI/injury

surveillance requires building entirely new systems

that involve huge resources. This is not true.

Surveillance program can be built within existing

systems with minimal resources. These existing

systems can be improved, strengthened and utilized

to develop the requisite information (Gururaj et al,

2010).

For surveillance system to be effective, operational,

and sustainable, it should be simple, acceptable,

sensitive, reliable, representative, sustainable, timely,

cost effective, and most importantly useful. The

essence of surveillance is to collect small amounts

of good quality reliable information by scientific

approaches and utilize the information to develop

policies programs and interventions. As surveillance

is an ongoing activity the data would reveal the

efficacy and effectiveness of interventions as seen by

change in the injury burden and patterns.

A9. Data sources for surveillance

There are multiple sources of data for injuries in

India. Each source collects different types and

quantum of data for its own purposes. The common

sources of data are from vital registration systems,

police, transport, health, welfare, insurance, legal

sector and others.

Injury deaths in India are considered medicolegal events since historical times.

Consequently, the police department undertakes

investigation on all accidental and unnatural

deaths and details are documented as per

official procedures. Information on traffic

deaths is collected by the traffic division, while

intentional injury deaths are documented by

the crime division. Information on few other

injury deaths is also collected by law and order

division of police department. The available

information varies from place to place and

summary statistics are sent to NCRB which

compiles and publishes national statistics.

However, the information collected is mainly

from an administrative, criminal and legal

point of view and mechanisms to use

information for policies and programs are

totally lacking. Further, data analysis and

interpretation is not undertaken at state or local

levels.

Similarly, information on transport injuries isalso collected by the transport department.

Apart from information on type and number

of registered vehicles, the department also

collects and publishes data on deaths and

injuries. The published reports are somewhat

similar to NCRB reports with some additional

information on highway deaths and few

established indicators of road safety. However,

the periodicity of reports is not uniform and

there are delays in publication of these reports.

The vital registration system in every city anddistrict collect and compiles data on births and

deaths at local levels. Information on deaths is

collected (form no.4) and compiled regularly. ICD

10 coding is used in few cities and districts for

this purpose. The use of ICD 10 varies from place

to place and depends on completion of death

certificates in institutions and coding by

physicians. The local level data is available on

age, sex, place, cause while, ICD code details

are available in some situations. The accuracy

of information is influenced by completeness of

registration and quality of data at the local level.

13

Information on injuries and related deaths isalso collected by mortuary centres of selected

institutions as per legal requirements. Mortuary

data is collected by forensic medicine

professionals and stored for longer periods of

time due to legal requirements. Information

on sociodemographic details, cause of death,

situation- context circumstances of injury,

description of injury details and cause of death

are documented for every case. However, no

collective analysis is being done by any agency.

Currently, an ongoing study in Bangalore is

examining mechanisms to use autopsy data

for injury surveillance purposes (Gururaj,

2010a).

All hospitals document details of injury patientsand deaths for care and administrative reasons.

There is no uniformity and the practice varies

from hospital to hospital. There are no national

or state level guidelines for documenting details

of injury patients or even other patients.

Unfortunately, hospitals do not even bring out

summary statistics of their respective

institutions. The MCCD system collects data

from specific institutions for national and state

reporting systems (GOK, 2010).

Data on injury deaths are also available frominsurance sector. However, this data is not in

the public domain and cannot be accessed

easily for policy or research purposes.

In summary,

there are multiple sources of data

depth and quality of information varies

from agency to agency

no national or professional guidelines

exist for data collection (except for MLC

summary formats)

no uniform format exists for reporting

from hospitals

quality and nature of information has not

been examined

except NCRB, there is no national

coordinating agency

no agency exists for analysis,

interpretation and dissemination, and

data is rarely used for interventions,

policies and programs

A major drawback of the current situation is that

total information on all aspects of injuries is not

available in the public domain for planners, policy

analysts and researchers as the existing information

systems are fragmented, and piece meal in nature.

14 BRSIPP 2011

B1. Bangalore road safety and

injury prevention program

Section B:

The Program and Methods

The Bangalore Road Safety and Injury Prevention

Program (BRSIPP) was started in 2007 to develop

systematic activities for prevention and control of

road traffic injuries and other injuries. At the national

level, information available from the National Crime

Records Bureau through its annual reports of

Accidental deaths and Suicides in India provides

information on number of fatal and non fatal injuries,

age sex profiles, state and city wise distribution,

education and occupation levels, road user categories

for RTIs, time and period distribution, and a vague

distribution of causes for road traffic injuries,

suicides and all accidental deaths. While this

information is definitely helpful from a national

perspective, local data is required for a number of

activities. Hence, a surveillance approach was

adopted to gather information from multiple sources

in the city. This demonstration program attempted

to develop systematic road safety and injury

prevention programs based on data and evidence

adopting comprehensive and multiple approaches.

The overall goal of BRSIPP is to achieve a reduction

in injury (RTIs, suicides and others) deaths,

hospitalisations and disabilities in Bangalore along

with strengthening injury information systems.

The specific objectives of Bangalore Road Safety and

Injury Prevention Program were to:

1. Collect and analyse data from police sources,

selected participating health care institutions,

and transport sector on specific aspects of RTIs

and other injuries through a surveillance

approach.

2. Use data for road safety and injury prevention

programs at the city level to facilitate

development of road safety and injury

prevention through advocacy activities

3. Facilitate application and utilization of data

for planning and implementing general and

specific countermeasures through various

programs.

15

B2. Methods

In Bangalore, under the program, attempts were

made to generate data through specific mechanisms

and pool data from different sources. The program

has been strengthened during the last three years

and attempts are in progress to develop an integrated

data collection system. The extent, type and nature

of data to be collected were finalized in consultation

with stakeholders at the beginning of program.

Details of data collection activities have been

discussed in earlier reports of 2009 and 2010 (Gururaj

et al, 2008 and 2010). The development phase focused

on consultation with stake holders, sources of data,

selection of centres, inventory of hospitals, pilot study,

organizing logistics of data collection, training

programs, testing validity and reliability of data

collection methods, feedback mechanisms and data

utilization aspects. The various sources of data in

the program are shown in Figure 7. Activities

undertaken during 3 years based on data collected

are discussed in later sections of this report. Some

salient aspects of data collection are highlighted below.

Figure 7: Sources of information for injuries

B3. Fatal injuries

Information on fatal injuries was collected from two

sources: city police and vital statistics division of

the city administration. As all injury deaths are

considered either unnatural or accidental, they

are routinely reported to police. Investigations

are undertaken as per established norms and

procedures. Under the program, information

was initially collected (in 2008 and 2009) through

paper based formats. Under the leadership of the

Additional Commissioner (Traffic and Road Safety),

Sri. Praveen Sood, the paper version has been

replaced with a web based format in 2010. The

computerization support was provided by the staff

of National Informatics Centre in the city. Since all

police stations in the city have been computerized

and there are identified writers and computer

programrs in each station, it was considered timely

and economical to shift to this method. Number of

training programs has been conducted for writers

and inspectors of traffic divisions in each police

station during 2009 and 2010 to implement and

improve the system. The writers complete a two page

proforma for every road death soon after completing

investigation formalities.

The proforma has five sections of basic identification

details, injury details (intent, type, place of injury,

product involved etc), details of Road traffic injuries

(place of occurrence, collision patterns, risk factors

(alcohol), use of safety devices (helmet and seatbelts)

and trauma care details (first aid, mode of

transportation etc) (Annexure 1).

Since it was not possible to collect detailed

information on other non-traffic injury deaths

(Annexure 2), primarily deaths due to intentional

16 BRSIPP 2011

injuries, in the urban component of the program,

summary statistics was obtained from the office of

the City Crime Records Bureau. This was compiled

for 2010 on different parameters and injury causes.

A similar mechanism has been developed under the

rural component of Bangalore Road Safety and Injury

Prevention Program in Tumkur. Since there are no

networked computer systems in the district, a paper

based format is being used and data is collected by

the team of trained research officers from NIMHANS.

The designated staff from the coordinating centre

collect information from individual records of traffic

and non-traffic deaths (primarily accidental and

intentional injuries) from the police headquarters of

Tumkur District. With computerization process in

the offing, it is hoped that there will be a shift to a

web based format in due course of time. This

mechanism is being strengthened through an ongoing

District Road Safety and injury Prevention program

with support from WHO and Ministry of Health

(Gururaj, 2010b).

In addition, a separate program has been established

in the Bangalore Metropolitan Transport department

(BMTC) to record information on all fatal bus crashes

in the city. In consultation with senior officials, a

procedure was introduced to document details of

each fatal crash involving buses. The proforma is

completed by the designated trained staff of BMTC

and transferred to Co-ordinating Centre (CC) on a

monthly basis.

Information was also collected from city vital

statistics division and latest data available was for

the year 2009. Under the Births and Deaths

Registration Act, each death has to be registered

using specific formats which include the cause of

death. In Bangalore, under the MCCD scheme, data

is collected from the different hospitals and is

compiled at the city level. This was also used to

examine injury deaths under the program.

A feasibility study has been initiated in December

2010 to collect data from 9 mortuary centres in the

city with support from WHO. Considering the

advantages of small number of centres and the legal

requirements of autopsy for all injury deaths, a

mechanism has been developed to obtain accurate

and reliable data from all autopsies of injury deaths

(Gururaj, 2010a) (Annexure 3).

B4. Nonfatal injuries

Information on non fatal injuries was collected in

2010 from hospital sources in both urban and rural

components of the program. In Bangalore City, the

program that was started in 2007 continued with

all the hospitals (3 of the hospitals discontinued due

to variety of reasons). Based on the feasibility study

and the practical difficulties encountered in 3 of the

hospitals (Victoria hospital, Bowring hospital and

St. Johns Hospital), data collection in these places

is being done by the CC staff. In all other hospitals,

data collection is undertaken by the hospital

designated team in the emergency room division,

which varies from institution to institution.

In rural areas, the information was collected by the

Casualty Medical Officers (CMOs) in Sri Siddhartha

Medical College Hospital. In the district hospital

and three of the community health centres, this is

undertaken by the hospital staff themselves from 2011

and it is expected to lead towards a sustainable long

term mechanism (ETCR, Anneure 4).

The collection of data is done by the ER team (nurses

or doctors) using Emergency Trauma Care Record.

During the last 3 years, a number of training

programs were conducted for ER staff at regularly.

The work in each hospital is supervised by a nodal

17

officer of the hospital and monitored on a weekly /

monthly basis by the CC staff. The focus of

information collection was on

Basic identification and brief socio-demographic details

Information on Injury and death (place, type,activity, intent)

Details of road traffic deaths (where, who, howand selected risk factors)

Details of other types of injury and deaths(intent, place, type),

Pre-hospital care (first aid, transport, referral) Management and outcome

The research component of the program was

approved by the institutional ethics committee of

NIMHANS in 2007.

B5. Population based observational surveys

In addition to the routinely collected data, special

surveys were undertaken by the coordinating centre

during January-February 2011 in focused areas.

These population based surveys in the geographically

defined boundaries of the city focused on helmet

use patterns, drinking and driving issues, speed

monitoring by police, seat belt use and pedestrian

safety issues. Detailed survey procedures are given

in later sections of the report under individual

areas.

B6. Data pooling

Data pooling was done during the year from

information available with transport department

especially with regard to motorization changes and

patterns. Information available in the annual report

was made use of for this purpose and remaining

data was collected from individual RTOs in the

city.

Information on traffic violations was collected from

the Traffic Management Centre under Bangalore City

Police of the city to examine pattern and nature of

violations, fines collected and level of enforcement

in the city.

Further, data on infrastructural projects of the city

was collected from Bruhat Bengaluru Mahangara

Palike (BBMP) and Bangalore Development Authority

(BDA) to identify completed projects during the year.

In summary, different sources of data were identified

and relevant information was collected to develop a

comprehensive picture of fatal and nonfatal injuries

for the city of Bangalore. Even though the major

focus was on road deaths and injuries, data was

collected for other injury causes as well. In addition,

the collected data was used for number of activities

as detailed in later sections of this report.

B7. Monitoring of activities

Inbuilt mechanisms have been developed to ensure

systematic monitoring of the program.

At the hospital level, data collected fromcasualty is cross checked with medical records

and statistics to ensure coverage of cases.

At the ER level, the nodal officers ensureinclusion of all cases, completeness of all forms,

transfer to a location in ER for storage and

transfer to coordinating centre periodically.

Coordinating centre staff ensure uniformity and

completeness of data collection with random

checks and independent monitoring of 5% cases.

A weekly meeting (Saturday) was held regularlyto monitor progress, recognize problems,

identify solutions and review progress.

All received forms from different sources wereexamined for coverage and completeness.

Missing information was filled up from other

institutional records, wherever possible.

18 BRSIPP 2011

Meeting with all nodal officers once in 3 monthshelped in reviewing progress, identifying

remedial measures for problems, ensured

better cooperation, and work out future

steps.

Continuous contact of CC staff with allinstitutions was an inbuilt activity under

the program. Periodical visits and

communications on a regular basis was

undertaken to ensure completion of all activities

as per time schedule.

The program coordinator and the team visitpolice stations and hospital departments at

periodical intervals and held discussions with

nodal officers, ER staff, medical record staff

and hospital administrator.

All data received from different sources werechecked for coverage, completeness and quality

by CC staff. Data was then entered into the

computer on a day to day basis. Data entry

and check formats have been developed using

EPI - INFO package.

B8. Sharing and disseminating of information

Surveillance is an ongoing continuous activity,and the analysed data has to be shared with

all the partners; hence, feedback becomes a

regular feature of the program. As discussed

in the stakeholders and nodal officers meeting,

information was disseminated in number of

ways. The primary reason for using so many

combined methods was to encourage people

to get actively involved and also to ensure that

feedback becomes an inbuilt activity.

All reports have been developed, circulated anddisseminated under the title of Bangalore Road

Safety and Injury Prevention Program

Individual institutions were provided withtheir respective data (on a CD) on a regular

basis. Member institutions were encouraged to

examine, use and develop reports for their

institutional activities.

Data was constantly reviewed in the nodal

officers meeting and used in all training

programs.

Specific detailed information has been

made available to member institutions as

and when required.

In 2009 and 2010, the annual reports, set

of 10 fact sheets (Injury, Child injury,

Injuries among elderly, road traffic injury,

two wheeler safety, pedestrian safety,

suicides, falls, burns, poisoning), 5 public

health alerts (Helmets, Seatbelts, Drinking

and driving, Speed management, trauma

care) and 4 injury prevention series

(Education, Engineering, Enforcement

and Emergency care) have been published

and disseminated under the program.

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