Passion for peace drives IPPNW research in Liberia

Photo: Lucie Collinson

Results of hospital-based research in Liberia on armed violence spearheaded by members of IPPNW was published recently by the Small Arms Survey in Switzerland. A main finding of The Value of Hospital Data – Understanding and Preventing Intentional Injury in Liberia was that the Liberian Armed Violence Observatory (LAVO) is not receiving all the data it needs to most effectively inform intervention strategies on armed violence prevention.

“Our analysis of hospital data, as compared to data provided to LAVO by the same hospitals and by the media and police, revealed considerable variations—in terms of both the quantity and the quality of the data,” said co-author Dr. Lucie Collinson. “LAVO’s ability to identify trends in armed violence is challenged by the lack of comprehensive data.”

Some important discrepancies surfaced during the research, including that sex-disaggregated hospital data is not always efficiently captured by LAVO. For example, while one hospital audit based on ED attendance notes showed that 57 per cent of the victims of interpersonal injuries were women, LAVO’s data from the same hospital indicated only 40 per cent. Moreover, LAVO’s data from media reports and police records showed that women accounted for only 27 per cent of the victims over the same time period.

Given that the LAVO armed violence surveillance model is being replicated in other African countries, such as Sierra Leone, enhancing the flow of quality data from hospitals to LAVO can also be expected to maximize the effectiveness of future observatories in this region and others. An observatory’s ability to inform effective violence prevention strategies depends on efficient, accurate and comprehensive data collection and timely sharing of quality data.

Post-conflict conditions in Liberia a motivation for the research

The project was initiated by Dr. Andrew Winnington from the New Zealand (NZ) branch of IPPNW, and joined and completed by Dr. Collinson, a public health physician in training in the UK, with assistance from Mary Vriniotis, a US-based researcher. Action on Armed Violence (AOAV), the UK-based organization that established the LAVO in March 2011, provided significant assistance on the ground in Liberia with both logistical and administrative support.

After an initial scoping study, Drs. Winnington and Collinson both spent several weeks at two hospitals in Liberia’s capital, Monrovia, reviewing and documenting medical records of patients suffering intentional injuries. The goal was to assess the completeness of the data supplied to LAVO from hospitals, which was established in 2011 as an independent institution.

Dr. Winnington in Liberia

According to the 2015 Fund for Peace “Fragile States Index,” Liberia is considered a “high alert” fragile state with great instability. Why did they volunteer for this difficult research in such a volatile part of the world?

“High levels of violence have characterized Liberia’s post-conflict transition. I wanted to investigate how LAVO operated so I could replicate it in the Pacific to monitor for any regional increase in gun violence. Diplomacy efforts can then be focused into trouble spots and aim to prevent conflict from scaling up,” said Dr. Winnington. “I am passionate about peace in the Pacific and want to prevent any more wars in the Pacific fueled by corporate greed.”

Dr. Collinson added, “I share Andrew’s passion for preventing violence, and recognize the value of healthcare data in informing violence prevention interventions. Healthcare data can capture intentional injuries not reported to the police, media or other sources such as in cases of domestic violence or other criminal activity. Unfortunately, healthcare data is often an untapped resource. I was motivated to take part in this research to support LAVO in their great work by evaluating their efforts to ensure that their methods are as robust as possible. Accurate data on the survivors, perpetrators and mechanisms of intentional injuries is vital to identify risk factors and accordingly inform violence prevention strategies. Incomplete and inaccurate data can lead to misinformation and false conclusions being drawn,” she said.

Patrick Nshamdze, who helped IPPNW doctors gain access to medical records,  died from Ebola – the report is dedicated to him.
Photo: Lucie Collinson

“I also wanted to power up LAVO by providing them with a tool to extract medical data from hospitals,” said Dr. Winnington.

U.S.-based researcher Mary Vriniotis joined Drs. Winnington and Collinson in New Zealand to help crunch the numbers and analyze the volumes of data the two had collected in Monrovia.

“The results of the study underscore that hospitals are critical sources of data that can be used to investigate and ultimately prevent intentional injuries,” said Ms. Vriniotis. “While other observatory data sources were not audited as part of this work, the study highlights the importance of funding audits as a core component of evaluating and improving the work of observatories.”

Previous work by IPPNW doctors in multiple African countries has also identified the value of hospital data in understanding and preventing intentional injuries and has tested a surveillance tool that optimized data collection in the hospital setting. To assist data collection by LAVO, the IPPNW-NZ led project introduced a modified version of the tool in an easy to use sticker format. The sticker makes it quicker and easier to record useful information about injuries as patients are admitted as well as making the information collected more comprehensive and the injury cases easier to identify among medical records.

While use of the tool was never formally implemented, LAVO and hospital staff could be trained or retrained to employ it.

Study recommendations:
• Hospitals are critical sources of data that can be used to investigate and prevent violent injuries; hospital data collection and reporting to LAVO on intentional injuries from violence should be improved as much as possible.
• It would be useful for LAVO to be supplied with hospital morgue records, which can serve as an important source of data on fatal injuries. At this writing death certificates in Liberia contained only limited information relating to aspects of violent injuries.
• Hospital staff could make use of computers available in each hospital to collect and store data. This practice would also help in the production and dissemination of monthly statistics for the Ministry of Health and Social Welfare on all hospital attendances. At this writing, only one hospital in Liberia reportedly had an electronic admissions form, while others recorded data manually.
• An important objective of this research project was to build the capacity of health professionals and researchers in Liberia to measure and monitor levels of intentional injuries. Building networks and cultivating collaborations are key to the successful implementation of data collection tools such as the sticker tool shown here, as well as to gaining future access to other hospitals and maintaining access to Redemption and St. Joseph’s hospitals.
• Regular audits of observatory data collection methods from all sources could help identify and minimize discrepancies in reporting.

Dr. Winnington no longer practices clinical medicine, but has gone into business (www.xyleap.com), “so I can use capitalism to build peace and to fund projects like sending medical students to IPPNW conferences, funding disarmament research projects, and building an Armed Violence Observatory in the Pacific,” he said.

The Liberia work was funded by the Peace and Disarmament Education Trust of NZ (with money derived from the reparation payments by the French Government after they bombed the Greenpeace vessel the Rainbow Warrior in Auckland harbor in 1985) and Small Arms Survey with in-kind contributions by the researchers and IPPNW.