The method as outlined in Injury surveillance guidelines  and surveillance training manual  of the World Health Organization and Centres for Disease Control and Prevention was adapted for this study.
The Study Setting
Kaduna State, North-Western Nigeria, has 23 local governments with Kaduna metropolis as its capital. Kaduna is an industrial centre and a former administrative seat of Northern Nigeria. It is the third-largest city in Nigeria with 1.9 million people as the estimated population in 2015. This cosmopolitan city, covering an area of 3,080 Km/m2 is about 200 km from Abuja the federation capital city. Being a transit town from Abuja the nation’s capital to the 18 Northern states, it has a high volume of vehicular movement with 3 major highways traversing the metropolis. Although the city is rapidly growing in motor vehicle ownership, in 2006 it witnessed a considerable increase in the average of 4,000 vehicular registration per annum , mostly using two-, three- and four-wheel vehicles for transportation. In 2013, the use of a protective helmet by motorcyclist was legalized but was not enforced in the state.
RTI Stakeholders' Identification And Collaboration
The identified stakeholders of RTI surveillance in Kaduna Metropolis are FRSC, health workers at Accident and Emergency (A & E), Pathology/mortuary, Police Motor Traffic Division, Road transport workers, Ministry of Roads and Transport, Ministry of Health, Journalists, Civil Society Organisations and the public. Following the advocacy visits, the stakeholders brainstorm and developed an RTI surveillance mechanism, design data tools, defined monitoring indicators and met every 3 months to review the progress of the study. A case was defined as any person in Kaduna metropolis killed or died within 30 days because of injuries incurred from a collision on a public road involving at least one moving vehicle. The cases were identified, investigated and reported by the designated RTI reporting site [17, 18].
The following indicators were developed for monitoring:
- Total number of road traffic crashes that occurred within a reporting month
- Total number of people injured following road traffic crashes (minor, severe and fatal)
- The proportion of the people injured that resulted from a crash without no primary object of a collision that occurred within a reporting month. The denominator is the total number of the injured.
- The proportion of the injured following a crash that was transferred by the Police to the health facility within a reporting month. The denominator is the total number of the injured.
- The proportion of the injured following a crash that was transferred by the FRSC to the health facility within a reporting month. The denominator is the total number of the injured.
- The proportion of the injured that used safety element during the crash. The denominator is the total number of the injured.
- The proportion of those that died (fatally injured) following road traffic injury within a reporting month. The denominator is the total number of the injured.
- The proportion of death that occurred at the health facility among the fatally injured within a reporting month. The denominator is the total number of fatally injured.
- Timeliness: Proportion of reporting sites that sends the monthly data before the end of five working days of the succeeding month.
- Completeness: Proportion of reporting sites that send a completed monthly RTI data, including zero reporting.
RTI Data Collection Sources
Three major health facilities with high volumes of road traffic injury cases in the Kaduna metropolis, Kaduna State Nigeria e.g., Barau Dikko Teaching Hospital (BDTH), St. Gerald Catholic Hospital (SGCH) and 44 Army Reference Hospital were purposefully selected health facilities for this study. Other sectors or disciplines selected were The Police Motor Traffic Division (MTD) and lastly, the Federal Road Safety Corps (FRSC).
Using the existing FRSC and police motor traffic division’s RTI surveillance data collection tools, three data collection tools were developed. Two of the data tools were paper-based and the last was electronic. The paper-based individual case-based form was used at the health facility and consisted of three sections; a section for demographic information like name, age, sex, address, occupation, crash number, case number, reporting date and name of reporting health facility; section on injury include variables such as date of the crash, time, location, mode of travelling, what the vehicle collided with, type of location (highway, road, street), and disposal from the crash site and injury description were reported; the last and third section includes post-crash care which includes information on the date of presentation at the health facility, time of presentation, time is seen by the healthcare worker, prior presentation at the health facility and where, who transported the victim to the health facility, vital signs on presentation (pulse rate, blood pressure, temperature, respiration rate), preliminary diagnosis, emergency treatment and disposal or outcome at Accident & Emergency were reported.
The second paper-based data tool was a monthly summary form. It includes such variables as the name of reporting health facility, date and time of the crash, number of the crash, age and sex of the injured and outcome of the crash (fatal, serious or minor), the crash site, the probable cause of accident and type of vehicle involved and the outcome. The electronic form is an excel Microsoft spreadsheet used to line-list RTI cases as seen by each reporting facility. Data were sent monthly to the data manager before the end of the first five working days of the subsequent month and principal investigator provided feedback monthly.
Injury severity was classified into mild, moderate, and severe or fatal. The mild injury was an injury sustained following road crashes without hospitalization of the injured e.g., bruises or abrasion, contusion, minor lacerations, and other soft tissue injuries. Moderate injury included any fracture, spinal cord injury, loss of consciousness or vital-organ involvement that warranted a stay in the hospital, while severe or fatal injury was life-threatening conditions that resulted in death. The primary object of the collision was an object i.e., vehicles, road pavement, pedestrian, stationary objects like poles, packed vehicles etc., that a moving vehicle collided with during the crash and road was classified according to the number of lanes i.e., four- and two-lane roads.
Data were collected between February to July 2016 by trained data collectors and their supervisors. Data were collected at the crash sites by the police and FRSC and move the victims to the health facility. At the health facilities, data collectors interviewed anyone presenting with RTI after they had been seen and clinically stabilised by the clinicians. In cases where the injured had been admitted into the wards within the hospital, data were collected at the ward if stable. Otherwise if unstable, dead, referred to other health facilities not included in the piloting surveillance or had been discharged before the interview, the data were extracted from the victim’s health records. Also, data collectors actively search registers at A&E, General Outpatient Department (GOPD), autopsy or pathology department and mortuary to retrieve information on RTI cases. For RTI cases brought to the health facilities by the Police and FRSC data were collaborated between the two reporting sectors and duplicates marked in the line-listing of each sector.
At the end of each day, data collected were line listed on the Microsoft excel sheet and sent to data manager at the end of each month and together with individual case-based form, summary form and the excel line-list (e-copy form) latest within the five working days of succeeding month and duplicated copies were removed from the database. Zero reporting was allowed, and missing variables in the health records were coded “99”. The supervisors in each reporting site validated the RTI data by checking for data completeness of the individual case-based form compared with the excel line list before submitting to the data manager.
The data were cleaned and uniformly standardized by removing any abbreviations, hyphens, incorrectly written alphabets, formatting date of birth and code “99” for missing variables. The data manager linked datasets from the health facilities with RTI data from the police and FRSC using a deterministic or rule-based method. The linkage was based on an agreement between four to six of these variables; hospital number, name, age, sex, address, date of the crash, location of the crash, who transferred to health facility, any prior health facility visit, and name of the previous hospital visited. If the RTI case from two reporting sites matched and assumed to be duplicated, one of such matched data is retained for analysis. Finally, the data were consolidated on a single Excel Microsoft spreadsheet and exported into Epi-info statistical software version 7 for analysis.
Descriptive analysis such as frequencies and proportions were calculated and presented in tables, charts and trends analysis of some indicators. Odds ratios were used to calculate association with moderate to fatal injury. Variables with a greater proportion of non-completeness such as the use of alcohol, documentation of injury site, type and Abbreviated Injury Scale (AIS) score, preliminary diagnosis using International Classification of Diseases (ICD) codes were exempted from analysis as most are not documented by the attending health workers.
A two-day hands-on-training on data tools was conducted for supervisors and data collectors on the use of data tools, RTI surveillance system, data collection, storage, transfer, processing and dissemination. After the training and one month before the commencement of the study, the tools were pretested on RTI patients at the health facilities selected for the pilot study, for both interviewer and interviewee comprehension of the variables, acceptability, simplicity of use and time of administration. The identified corrections were made to the final draft of the questionnaire.
Ethical approval was granted by the Kaduna State Ministry of Health and Human Services Institution Review Board with reference number MOH/ADM/744/Vol.1/366. Participants or relatives were duly informed and verbal or written consent or assent was obtained before the interview. Participant privacy and confidentiality was maintained, and data were anonymised before analysis.