Puspa Raj Pant 1 , Prof Elizabeth Towner 1 , Matthew Ellis 2 and Paul Pilkington 1

Community perceptions of childhood injuries and its prevention measures in Nepal: a qualitative study Puspa Raj Pant1 , Prof Elizabeth Towner1, Matthew Ellis2 and Paul Pilkington1 1University of the West of England; 2University of Bristol Email: puspa.pant@uwe.ac.uk

Objective To obtain an in-depth understanding of people’s perception about the causes and their concepts of prevention of childhood injuries in Nepal.

Methods • Qualitative study using focus group discussions and key informant interviews. • Three communities of Makwanpur district. • FGD participants: female community health volunteers, school children and mothers. • Out of 27 FGD participants 21 were female. • KII participants: paramedics, Child NGO worker, Child protection officer and a teacher.

Results (1) • 'Injury' was understood as an event with discernible and severe outcomes, leaving the mild to moderate injuries ignored. All children have injuries. “It is usual to have small cut bruises [to children.]” (Mother #7) “These all [showing scar on their hands] were the marks of cut we had in the past. You get cuts when you are cutting grass. [We don't think] it is important to mention here.” (Mother #9)

Results (2) • Fatalistic understanding. “It [injury] is said to happen because of an ill-fate. They are supposed to be unfortunate [children].” (all mothers equivocally) “...early in the morning his grandma cursed him – may this (boy) die in the mill. What she said happened. He died. The poor boy was pulled in by the belt [of the flour mill]” (Mother #6)

Result (3) • The most common causes of child injuries were related to their everyday activities. Risk-taking behaviours among grownup children. “In spite of his uncle and father's prohibition of using a motorcycle since he doesn't know how to ride it properly he took it without listening to them. After some time he ploughed the motorbike into the field near Chundada[all participants laugh on this statement]. Then he returned and was lying down on the bed. We asked him what happened to him but he didn't tell anything. When we checked his body we found he had bruises and wounds everywhere on his body.” (health volunteer #7)

Result (4) • … and ignorance and lack of knowledge. “This is either unawareness or ignorance. If they have knowledge sometimes it is the negligence of family members [about potential risks of accidents]. Secondly, they really don’t know anything. Thirdly, they don’t follow our suggestions! These are three main things [for accidents in our community].”(health volunteer #2)

Result (5) • Participants related child injuries with illiteracy and poverty. “The children come to hospital after falling from trees. They [parents] sell a quintal of maize, or paddy or other grains [to cover treatment costs]…… Many of those [children] with fractures have to go to private clinics; many have to go to Bharatpur medical college. There are ambulance costs and other costs. All of them are not able to bear these costs…… I have seen some parents talking to doctors – Doctor, please do it here, whatever possible, I cannot take him/her to Bharatpur for further treatment because I am short of money. Many of them return to home [without treatment].” (KI #3)

Result (6) • Suggested solutions Special attention to child supervision was the most frequently expressed measure of injury prevention to young children. Imparting skills around child injury prevention to mothers and community people Introduction of injury prevention awareness in the community

Perceived challenges • Participants felt that road accidents were the main causes of injuries but they were able to explain many causes, circumstances and preventive practices when questioned. • Child injuries were largely ignored because this issue was rarely discussed in a practical manner to prevent them. • Injury events can not be predicted • Existing practices • No institutional infrastructure around child safeguarding and injury prevention

Strengths • Focus groups were conducted along side of the HH survey • In-depth interviews with professionals with particular responsibilities for children • Included people from different strata of social life • First time discussion about injuries

Limitations • Effect of people’s own understanding about injuries and related terms • Students FGD and Key informants tended to incline towards Road Traffic Injuries

Conclusion • Although child injuries were largely ignored, participants realised their importance • Participants remembered various examples of injuries in the past. • Community people and child protection professionals were keen on injury prevention

Acknowledgements • Royal Society for the Prevention of Accidents • Department of Violence and Injury Prevention, World Health Organisation • Mother and Infant Research Activities (MIRA) • Participants of FGD and key informants

Puspa Raj Pant 1 , Prof Elizabeth Towner 1 , Matthew Ellis 2 and Paul Pilkington 1