issue brief TLAVA TIMOR!LESTE ARMED VIOLENCE ASSESSMENT Number 4 | October 2009 Tracking violence in Timor-Leste A sample of emergency room data, 2006–08 Introduction ! " e portion of recorded injuries seen at Dili National Hospital’s statistical unit and to National Hospital attributable to violence data made available by the UN Integrated Accurate data on the incidence and fell from 59 per cent in 2006 to 36 per Mission in Timor-Leste (UNMIT), which characteristics of violent injuries can be cent in 2008. Injuries caused by weapons is also conducting ongoing violent injury a powerful tool for understanding and associated with urban gang warfare— tracking. " e Issue Brief concludes with responding to armed violence. Record arrows, knives, and machetes—dropped a review of the problems encountered keeping by hospitals, clinics, and other from 17 per cent to 6 per cent in the same in conducting this research and with a health facilities on the nature of injuries period, and injuries caused by # sts, stones, consideration of current challenges to can provide crucial information on who and sticks dropped from 36 per cent to 24 hospital-based surveillance in Timor-Leste, is being injured, how, where, and under per cent. " e portion of recorded injuries noting the obstacles still to be overcome to what circumstances. Data is essential for attributable to tra& c accidents rose from 41 achieve consistent, reliable, and timely data gaining a better understanding of the risk per cent to 57 per cent. collection and dissemination. factors for victimization among di! erent ! segments of the population and for the " e portion of recorded injuries seen at design of interventions to reduce those risks. Baucau Hospital attributable to violence Hospital characteristics To be most useful for guiding prevention rose from 34 per cent in 2006 to 48 per and procedures activities, however, injury data should be cent in 2008, but data coding problems " ere are six government-operated hospitals standardized, detail rich, and collected make it di& cult to elaborate—or even in Timor-Leste with a total bed capacity systematically as part of a public health con# rm—this # nding. Tra& c injuries of approximately 500.1 " e Dili Hospital surveillance system. " is in turn requires reportedly dropped from 66 per cent of all Nacional Guido Valadares (henceforth uniform information management systems, cases to 52 per cent in the same period. Dili Hospital), with 264 beds, is the best the commitment of personnel time and ! Data from Maliana Hospital had to be equipped. " e # ve regional hospitals, each resources, and motivated stakeholders excluded from the analysis due to the lack based in district headquarters—Baucau, willing to provide sustained support. of ER records for 2006 and 2007: in only Maliana, Oecussi, Suai, and Maubisse— one-third of all cases could a cause of Under an agreement with the Ministry of feature smaller facilities. All are equipped to injury be determined. Health, the Timor-Leste Armed Violence provide at least basic surgical care. Patients ! Assessment (TLAVA) was given access to Almost one-# % h of all women presenting needing urgent care are admitted through patient data from three hospitals for the at ERs in Dili and Baucau hospitals were the public patient registry or ambulance gate years 2006–08. " e objectives were to collect recorded as victims of domestic violence; into the ER. ER sta! and doctors called in and analyse the data in order to identify the proportion rose to one-third for from other departments o% en determine incidents, trends, and risk factors for armed women aged 20–39 years. initial treatment and possible transfer violence following the 2006 crisis and 2007 ! Men aged 15–34 years, and especially those to other units. For violent injuries, this unrest, and to assess the state of violent injury aged 20–29 years, appeared to predominate generally means surgical wards. surveillance in the country. " is study, while in ER visits for violence, suggesting that this Hospitals track departmental caseloads and subject to limitations and caveats, presents segment of the population is at greatest risk procedures through their own statistical one of the # rst longitudinal looks at violent of violent injury. victimization as re$ ected by cases treated at systems. " ese vary with the size and ! ER data is currently not su& ciently robust Timorese hospital emergency rooms (ERs). complexity of the hospitals. Dili Hospital or systematically recorded to provide a has developed a di! erentiated statistical A% er manually abstracting patient data reliable picture of interpersonal violence in unit with four full-time sta! members. In from ERs at Dili National Hospital, Maliana Timor-Leste society. Baucau Hospital, the second-largest facility Hospital, and Baucau Hospital, and a critical " is Issue Brief proceeds by providing an (114 beds), the medical records o& cer sees review of hospital record keeping processes, overview of the methods and objectives to statistical tasks. In Maliana Hospital (24 TLAVA # nds that: of hospital surveillance for understanding beds), statistical and reporting duties appear ! Almost half of the injuries (44 per cent) violent injury trends, and describes the to be less clearly di! erentiated from other recorded at ERs in Dili and Baucau current record keeping arrangements. It clerical work. " e variability is problematic hospitals from 2006 to 2008 were the then reviews the data collected by TLAVA for data collection and comparison, and result of violence, while 53 per cent were in three hospitals for the period 2006–08. hampered TLAVA researchers’ ability to due to tra& c accidents. TLAVA data is then compared to that of Dili draw conclusions from across hospitals. Timor-Leste Issue Brief October 2009 | 1 Box 1 What is ‘surveillance’? " e term ‘surveillance’, as applied in the # eld of public health, refers to the ongoing and systematic collection, analysis, and interpretation of health information.2 " e goal of injury surveillance—as it is with the surveillance of infectious disease—is to generate reliable data that can be used to inform rapid responses to emerging health crises (‘early warning’), and to plan long-term public policy responses. Critical to the value of surveillance is the standardized categorization and coding of medical conditions presented to health sta! . Accurate, standardized coding not only allows comparisons of disease and injury (or death) seen Baucau ER setting (staged). The attending physician records patient information in a diagnostic form. at a particular hospital, but makes The ER register book, under the physician’s left arm, was the exclusive data source for TLAVA’s research. aggregation with data from other © ALDO BENINI facilities possible, facilitating the analysis of the health situation of population photocopied templates, which are sent to TLAVA researchers transferred data on groups. When collected in a timely and the statistical unit or records o& cer. " e over 2,600 ER patients to spreadsheets. " e ongoing way and disseminated regularly, data is aggregated into summary statistics of initial objective was to analyse injury data pooled data can be used to monitor caseloads, procedures, and—increasingly— for the entire 36-month period of January the incidence of injury characteristics, diagnoses. " is system has limited capacities 2006 to December 2008. " e team began such as weapons-related injuries, in the to correlate individual patient data, and the by abstracting the data for the months of population at large. Epidemiological data it generates is not normally recorded June, July, and August each year, in order to analysis can identify speci# c risk factors in a way that facilitates statistical analysis. make rapid comparisons between the events for certain types of injuries among Notably, TLAVA could # nd no evidence that surrounding the crisis of 2006 and the unrest particular segments of the population, hospital statistics even captured the length of 2007—both of which took place in the such as knife injuries among young men summer months—and the relatively calm of patient stays. aged 15–24 years. summer period of 2008. " e data abstraction " e Dili Hospital statistical unit keeps its " e tenth update of the World Health process was far more burdensome on TLAVA data in digital spreadsheets, but relational Organization’s (WHO) International and hospital sta! than anticipated, however, database programs are not yet used. and plans to back# ll the intervening months Statistical Classi# cation of Diseases, 4 known as ICD-10, is the international " e Baucau Hospital records o& cer has had to be abandoned. standard diagnostic classi# cation started transferring handwritten report In addition, it quickly became clear that for recording health conditions in information to digital spreadsheets, but the statistical and records o& ces in the individuals who present at ERs, clinics, TLAVA has no information on the progress hospitals were either marginal (Baucau, and other acute care facilities.3 of computerization in the remaining Maliana), did not hold individual patient hospitals. " is meant that the TLAVA data data (statistical unit in Dili), or did not do " e extent to which patient data in Timor- collectors had to extract data from the statistics at all (records o& ce in Dili). As a Leste is digitized varies from one hospital to manual information bases—essentially the result, TLAVA data collectors fell back on another. In Dili National Hospital, computers admissions book—of the ERs. " e practical primary data sources, i.e. ER register entries. are networked within the statistical unit, but and conceptual challenges this presented are " e TLAVA data thus consisted initially not with other systems. Patient identi# ers discussed on pages 5–6. of 2,465 individual trauma patients seen are manually created at the registration desk in the ERs of Dili, Maliana, and Baucau or in the ER and do not always travel the full Data collected hospitals in June–August 2006, 2007, and length of an in-patient hospital stay, making 2008, a% er excluding 135 non-injury- it impossible to determine the total number To access data on injured patients treated related complaints.