Evaluation of First Aid for Snake Bite community education

Sunsari District, Nepal 2004

Raj Kumar Daugoda Owen Lewis

Nilambar Jah, Sanjib Sharma

BP Koirala Institute of Health Sciences Dharan, Nepal

IntroductionCobra, krait and viper bites often present to

BPKIHS Emergency Dept.Sometimes use of tourniquets has lead to

ischaemic complicationsPressure immobilisation was an unknown

method in the communityThis form of first aid is safer than tourniquet

but should not delay transport to nearest centre where anti-snake venom is available

Aim: To evaluate the effectiveness of a video on first aid for snakebite in community settings

Hypothesis: The planned health promotion for snakebite first aid, using appropriate demonstration methods will result in significant change in knowledge, attitude and practice as measured before and after the health promotion in local communities.

MethodType of Study:- Prospective evaluation study , Multiple

group pre-promotion and post-promotion.

Inclusion criteria:- Areas where higher incidence of snake bite according to Emergency record. (2001-2002)33

Exclusion Criteria:-Areas of Sunsari district where significantly very low incidence and Non-Incidence areas.

Sample Size:- Around 20 communities were chosen for first aid education giving priority to worst affected areas.

Of these 7 was chosen for evaluation ensuring balance of location and type of community so as to get a more representative convenience sample

Questionnaire was developed in general outpatients through giving first aid education

“The video was shown in the out patient area of GOPD as a site where a categorical style questionnaire was developed after more open ended style interactions with viewers”

QuestionnairePossible scores in brackets1. What would you do immediately if you or

your friend was bitten by a snake? (0, 0.5, 1)2. After snakebite, following first aid, which is

the best place to take the patient? (0,1)3. From where do you get anti-snake venom

(ASV)? (0,1)4. Have you heard about pressure bandage

immobilization method used in snakebite first aid? (0,1)

5. If you have heard, what’s that? (0,0.5,1)6. What do you do if a snake bites on head or

neck? (0,0.5,1)7. Name two poisonous snakes, in which

pressure bandage immobilization can be applied? (0,0.5,1)

8. Do you know the application of pressure bandage immobilization? (0,1)

9. If know the method of application of pressure bandage, how? (0,0.5,1)

Initial visit was made to meet community representatives, perform pre-promotion questionnaire and arranged the video showing to groups of people. Community leaders and health workers were targeted but who ever displayed interest was invited to participate including different age groups, genders etc.

Visited for video showing. After showing the video, community members

were given hands-on training in snakebite first aid technique and encouraged to use it in future. Emphasis was given to avoid use of tourniquet.

Subsequent visit 1-4 weeks later to perform post –promotion questionnaire interviews.

Open criteria for selection: Some individuals had completed the pre-promotion

questionnaire Some had actually seen the video, Some had neither completed pre-promotion

questionnaire nor seen the video(The aim was to interview anyone in that community to

assess whether the health promotion message had been passed on to others.)

Average Score by Question Number

0.00

0.50

1.00

1.50

1 2 3 4 5 6 7 8 9

Question

Sco

re

Pre-video Post-video

Average Score

0

0.2

0.4

0.6

0.8

1

Pre-video Post-video

Sco

re

Average Score

ResultsSeen video Not seen video

Number Ave Score Number Ave Score

Pre-video 0 - 87 0.214

Post-

video

52 0.926 34 0.894

Did age-group make any difference?Pre-video Post-video

Age group Number Ave Score Number Ave Score

>10 - 20 13 0.26 1 0.72

>20 - 30 18 0.21 41 0.91

>30 - 40 23 0.24 19 0.80

>40 - 50 21 0.19 15 0.99

>50 - 60 5 0.20 6 1.00

>60 - 70 1 0.23 4 0.83

not rec 6

Total 87 86

Did literacy make a difference?Pre-video Post-video

Literate Number Ave Score Number Ave Score

Yes 84 0.21 77 0.89

No 3 0.20 9 1.00

Total 87 86

DiscussionShort term change in knowledge demonstrated

Subsequently snake bite cases began to present to Emergency with variably applied pressure bandaging

Community groups requested to use the video

These phenomena died down as health promotion activity was not sustained

Emergency Dept practice is now to apply pressure bandaging on arrival and before any tourniquet is released

Impairment following snakebite; worth counting for advocacy purposes

Owen Lewis Senior Advisor Education and Disability,

Nossal Institute for Global Health, University of Melbourne olewis@unimelb.edu.au

Search for literature on impairment or disability following snakebite produces lean pickings.

However, the local damage caused by viperid and cobra bites is well known, as is the morbidity due to use of arterial tourniquets.

The outcomes in suspected snake bite in emergency department records may include local damage, but longer term outcome is unlikely to be systematically recorded as follow-up is so difficult to organise.

It is not surprising that there is so little literature available.

Medical categories do not take into account the broader social impact of snake bite

Costs to the community are manifoldthe fear of deaththe drama of conflicting ideas about appropriate action, the cost of transport and transport time without expert

helpthe long wait while being observed, the fear and uncertainty, the expensive anti-venom, its inherent risks, (N.B. riot in the emergency

department)the disturbance to work and equanimity for a number of

people.

Residual impairment and disability may be comparatively rare but are likely to be life long.

These impacts deserve study from a social point of view if society is to take the matter seriously enough to invest in strategies to reduce them.

Approach to disabilityAccess to public services including health are

needed with general infrastructure improvement

Reduction of stigma and discrimination, inclusion in social and economic activities, access to assistive devices (eg. prostheses, wheelchairs, etc).

Service development and disability trendsThe better management of complications of

snake bite will depend more on the development of general health services with a rehabilitative component in the periphery, rather than on highly specialised central ones.

The trend in approach to disability now strongly emphasises the social model of health – hence Community Based Rehabilitation is in season rather than institution based care

Need for burden of disease dataThe main purpose of research about residual

damage and disability will be to count the cost to the community, so as to attract more energy and resources for primary and secondary prevention.

Numerator has little value unless denominator is better known – this depends on general improvement in data collection

Follow-up study of snake biteTo obtain accurate pictures, longitudinal

studies are needed in places where it is feasible to set up reliable and comprehensive follow-up.

In resource poor settings this is more likely to be achieved in smaller locations with stable and accessible populations. (e.g. Damak!)

Community involvement in the research process is essential.