Critical connection: principles of the public health approach and contextual matters in injury policy and programs for resource constrained settings

Injury is recognised as a major contributor to the global burden of morbidity and mortality, causing approximately 6 million deaths per year and continuing to impede development in low-middle income countries (LMICs) where 90% of injury deaths occur. The main response this far has been a public health approach that applies the principles of public health at the population level by identifying risk factors and seeking to prevent injury by reducing exposure to known risks. However, the overall premise of this thesis is that the processes and impact of public health interventions are inevitably influenced by the context in which they are developed, implemented and evaluated. Therefore, the candidate aimed to develop a refined public health approach for translating injury data and research to practice and policy in the LMIC context. To realistically scope this thesis, the research focused on surveillance as an indicative vital element of the public health approach. The framework was developed through multiple stages: firstly, applying information from the literature, an understanding of the complex health transitions confronting LMICs and their implications for the injury burden and prevention efforts were examined. Next, a systematic review of the utility of the WHO Injury Surveillance Guidelines was used to assess the strengths and limitations of the current public health approach from a surveillance perspective to support LMIC injury policy and programs. Subsequently, a mortuary-based surveillance epidemiological tool was developed and piloted in six LMICs. Examination of case capture effectiveness and a process evaluation of implementing a fatal injury surveillance system in resource constrained settings were conducted. Mixed methods research was used to gather information on the factors influencing the establishment of fatal injury surveillance system in LMICs. Finally, based on these studies, an integrated, refined public health framework was developed. The research confirmed that developing countries are undergoing an epidemiological transition and identified multiple contextual factors that contribute to the burden of injury in LMICs including atypical and distinctive causes of injury, cultural beliefs regarding injury, political structure and influences, limited resources with underfunding of injury research and competing health priorities in the context of poverty. The systematic review identified that the utilization of the guidelines in LMICs was limited in terms of the quality of data generated using the tool, use of the default minimum dataset resulted in injury data that lacked detail for prevention and the tool was used mainly for short term non-fatal studies with very limited establishment of a sustainable injury surveillance system, particularly for fatal injuries. The pilot studies showed that the mortuary is a potentially useful source of injury data in countries with constrained resources and lack of quality data. However, despite improvements in both capture and detailed information on the circumstances of injury, eligible external cause deaths were found to be poorly captured and reported by the medico-legal system; there were apparent systemic issues, including cultural issues, and there was limited workforce capacity and training in injury surveillance systems with a lack of strong leadership for fatal injury surveillance. Based on this knowledge, a refined injury prevention framework is proposed, complementing the existing public health approach by accounting for the content, process, practice, policy environment and context. Consequently, for injury prevention in LMICs, a proposed framework complements both the public health and public policy approaches to incorporate the macro and micro level factors that influence injury data collection, prevention policy and programs.