Introduction: Over 80% of the world’s one billion tobacco smokers reside in low- and middle-income countries (LMICs); therefore, it is important to understand factors that promote intention to quit smoking in these countries. This study evaluated factors associated with three stages of intention to quit tobacco smoking among adults in LMICs. Methods: Data from 43,540 participants of the Global Adult Tobacco Survey in 14 LMICs were analyzed. Intentions to quit smoking were categorized into precontemplation (referent category), contemplation, and preparation stages based on the transtheoretical model. A multinomial logit model was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Results: Approximately 82%, 14%, and 4% of the smokers were in precontemplation, contemplation, and preparation stages, respectively. Rural residents had increased odds of being in contemplation stage (OR = 1.41, 95% CI = 1.09–1.83) compared to urban residents. Compared to homes where smoking was allowed, smoke-free homes were associated with increased odds of contemplation (OR = 1.77, 95% CI = 1.41–2.23) and preparation (OR = 2.18, 95% CI = 1.78–2.66). Exposure to anti-smoking messages in more than one media channel was associated with increased odds of contemplation (OR = 1.60, 95% CI = 1.33–1.92) and preparation (OR = 1.73, 95% CI = 1.28–2.33) compared to no exposure to anti-smoking messages. Conclusion: The results suggest that anti-smoking media campaigns and smoke-free policies may promote intention to quit smoking in LMICs. While these suggest the need for implementation of comprehensive anti-smoking campaigns and smoke-free policies, longitudinal studies are required to confirm these findings and to evaluate how intention to quit translates into quit attempts in LMICs.

Musculoskeletal trauma including fractures, represents a significant burden of disease for Low- and Middle-Income Countries (LMICs). Within LMICs, women possess reduced agency to make health care decisions and represent a vulnerable population. In this thesis, I aimed to characterize priority fractures among women within LMICs, and investigated whether women were delayed in hospital admission following an orthopaedic trauma. In Chapter 1, I introduce and review the existing literature on injury burden, health care deficiencies, and gender inequities within LMICs. In Chapter 2, we analyzed regional distributions of fracture burdens across 9,934 female orthopaedic trauma patients across 17 LMICs. Half of our study patients were ≥ 60 years old. We determined that the major burden of orthopaedic trauma among women within LMICs were fractures among the elderly. Fracture burden in Africa was notably different. A majority of patients were between the ages 18-59, and common fractures included tibia/fibula and femur fractures. In Chapter 3, we analyzed 26,910 orthopaedic trauma patients across 17 LMICs to determine whether women were delayed in hospital admission by >24 hours. After controlling for confounds, sex was not a significant predictor of delay. We found that instead, the severity and type of fracture influenced the delay of patient’s hospital admission. Closed fractures, falling-related injuries, pelvic, spine and hip fractures were associated with increasing delay. Irrespective of sex and region, inter-hospital referrals accounted for nearly half of the reasons patients were delayed. These two chapters highlight regional trends in orthopaedic burden sustained by women, pointing to the high frequency of fragility fractures. In addition, this thesis identifies critical gaps within LMICs’ health care systems infrastructure, demonstrating the need for improved hospital referral systems and ambulatory services. This analysis will enable policymakers, and future researchers to target interventions to address the rising global burden of injuries especially among women. / Thesis / Master of Science (MSc) / Fractures represent life-threatening injuries within Low- and Middle-Income Countries (LMICs), and globally are a top-ten leading cause of death and disability. Within LMICs, due to gender inequalities, women may be restricted from receiving hospital care following an injury. We investigated the most common types of fractures in women within LMICs and determined that women most frequently experienced fractures due to old age. We further examined whether women were delayed in reaching a hospital after sustaining a fracture, and found that sex did not significantly play a role in determining delay. Instead, injury associated factors, such as the type and severity of the fracture influenced whether a patient was delayed. In addition, transferring patients between hospitals was the most common reason for delay. As a result, policymakers in LMICs should explore strategies to treat the high burden of fractures in the elderly and improve communication between hospitals to reduce delays.

Health is deemed central to a nation’s development. Accordingly, health care reform and expansion are key policy priorities in developing countries. Many such nations are now testing various methods of funding and delivering health care to local disadvantaged populations. Similarly, India launched the Rashtriya Swasthya Bima Yojana (RSBY) national health insurance programme for low-income groups in 2008. The RSBY intends preventing catastrophic health-related expenditure by improving recipients’ access to hospital-based care. This thesis is an in-depth qualitative evaluation of the RSBY in Delhi state. It examines the RSBY’s effectiveness in fulfilling its goals and meeting local health care needs. Walt and Gilson’s (1994) actors-content-process-context model informs the research design and an actor-centred “responsive” (Stake 1975) or “constructivist” approach guides data analysis. Three research questions are examined: (i). Why was a health insurance programme launched and why now? Why was this model favoured over alternate methods of service expansion? (ii). Is the RSBY delivered as intended? If not, why? (iii) How does the RSBY affect patients’ access to services? The findings are based on documentary sources, observation of implementation sites and activities and 164 semi-structured interviews with RSBY policymakers, insurers, NGOs, doctors, and patients. The results show improved access to curative and surgical care for RSBY patients. However, RSBY’s focus on hospitalisation and omission of primary and outpatient services had undesired negative effects. The lack of ambulatory facilities led RSBY patients to self-medicate or use dubious quality informal providers. By only allowing inpatient care, the RSBY also seemingly encouraged the substitution of outpatient care with costlier hospitalisations. In effect, the RSBY’s design contributed to cost increases and poor patient outcomes. While more funds and human resources were needed to improve RSBY implementation, the performance of frontline agencies could potentially improve through more stable, longer-term contracts. Similarly, modifying RSBY’s monetary incentives for doctors may lead to better service delivery by them. By evaluating the RSBY’s strong points and shortcomings, this thesis provides key lessons on strengthening policy design and health service delivery in developing countries. Thereby, it makes a broader contribution to understanding the determinants of successful policymaking.

Resilience, as a trait, process or outcome, is the negation of an undesirable outcome or of an expected maladjustment in the context of an adversity. Young people represent a developmental stage in which there is a vulnerability to experience deleterious outcomes during adversity. The literature on risk and promotive factors for resilience in youth is compounded by narrative reviews which have not applied a rigorous search methodology and which have failed to operationalise resilience. To date, the majority of research in resilience for emotional distress has focussed on data collected in high income countries. The first paper presents a systematic review of the literature on risk and promotive factors for trait resilience in youth. The findings indicate that there are differences in the magnitude of association between trait resilience and various risk and promotive factors, which were conceptualised into biological, intrapersonal, interpersonal and environmental factors. The largest body of evidence reviewed pertained to intrapersonal risk and promotive factors for trait resilience. Factors predicting trait resilience were also identified. Implications for future research include addressing the methodological and sampling limitations of the reviewed studies. The second paper presents an empirical study investigating factors within a microsystem which differentiate adolescents with resilience for emotional distress and those vulnerable to emotion distress in India (<i>N</i> = 967) and in Peru (<i>N</i> = 606). Factors which predict low emotional distress in each country and factors which differentiate between low emotional distress Indian and Peruvian adolescents were additionally investigated. A cross-sectional exploratory investigation of secondary data was employed. The findings suggest that the profile of low vulnerability for emotional distress differs between different cultural contexts and contribute to an extraordinarily limited evidence-base in low and middle income contexts. Extensive additional research is required to delineate culturally-specific profiles of resilience for emotional distress in a bid to develop culturally-sensitive treatment targets.

PhD, Faculty of Health Sciences, University of the Witwatersrand / Background: In low- to middle-income countries, rising levels of overweight and obesity are a result of multiple transitions, in particular, a nutrition transition. Consequently, in these countries, metabolic diseases are contributing increasingly to disease burden, despite the persisting burden of undernutrition and infectious diseases. Understanding the patterns and factors associated with persistent undernutrition and emerging obesity in children and adolescents, and concomitant risk for metabolic disease, is therefore of criticial importance. This should contribute to public health policy on interventions to prevent adult disease. Aims: To better understand the double burden of malnutrition in a poor, high HIV prevalent, transitional society in a middle-income country; In so doing, to inform policies and interventions to address the double burden of malnutrition. Methods: A cross-sectional growth survey was conducted in 2007 targeting 4000 children and adolescents 1-20 years of age living in rural South Africa. The survey was nested within the ongoing Agincourt Health and Socio-demographic Surveillance System, which acted as the sampling frame and also provided data for explanatory variables. Anthropometric measurements were performed on all participants using standard procedures. In addition, HIV testing was done on children aged 1 to 5 years and Tanner pubertal assessment was conducted among adolescents 9-20 years. A one-year follow-up of HIV positive children included a matched control group of HIV negative counterparts. Data collection involved both quantitative and qualitative methods. Growth z-scores were used to determine stunting, underweight and wasting and were generated using the 2006 WHO growth standards for children up to five years and the 1977 NCHS/WHO reference for older children. Overweight and obesity were determined using the International Obesity Task Force cut-offs for BMI for children aged up to 17 years and adult cut offs of BMI =25 and =30 kg/m2 for overweight and obesity respectively for adolescents 18 to 20 years. Waist circumference cut-offs of =94cm for males and =80cm for females, and waist-to-height ratio of 0.5 for both sexes, were used to determine central obesity and hence metabolic disease risk in ix adolescents. Descriptive analysis described patterns of nutritional status by age, sex, pubertal stage and HIV status. Linear and logistic regression was done to determine predictors of nutrional outcomes. A p-value of <0.05 was considered statistically significant. Results: Prevalence of undernutrition, particularly stunting, was substantial: 18% among children aged 1-4 years, with a peak of 32% in children at one year of age. Stunting and underweight were also substantial in adolescent boys, with underweight reaching a peak of 19% at 14 years of age. Concurrently, the prevalence of combined overweight and obesity, almost non-existent in boys, was prominent among adolescent girls, increasing with age, and reaching a peak of 25% at 18 years. Risk for metabolic disease using waist circumference cut-offs was substantial among adolescents, particularly girls, increasing with sexual maturation, and reaching a peak of 35% at Tanner stage 5. Prevalence of HIV in children aged 1-4 years was 4.4%. HIV positive children had poorer nutritional outcomes than that of HIV negative children in 2007. The impact of paediatric HIV on nutritional status at community level was, however, not significant. Significant predictors of undernutrition in children aged 1-4 years, documented at child, maternal, household and community levels, included child’s HIV status, age and birth weight; maternal age; age of household head; and area of residence. Significant predictors of overweight/obesity and risk for metabolic disease in adolescents aged 10-20 years, documented at individual/child and household levels included child’s age, sex and pubertal development; and household-level food security, socio-economic status, and household head’s highest education level. There was a high acceptance rate for the HIV test (95%). One year following the test, almost all caregivers had accepted and valued knowing their child’s HIV status, indicating that it enhanced their competency in caregiving. Additionally, nutritional status of HIV positive children had improved significantly within a year of follow-up. Conclusions: The study describes co-existing child stunting and adolescent overweight/obesity and risk for metabolic disease in a society undergoing nutrition transition. While likely that this profile reflects changes in nutrition and diet, variation in infectious disease burden, physical activity patterns, and social influences need to be investigated. The findings are critical in the wake of the rising public health importance of metabolic diseases in low- to middle-income countries, despite the unfinished agenda of undernutrition and infectious diseases. Clearly, policies and interventions to address malnutrition in this and other transitional societies need to be double-pronged. In addition, gender-biased nutritional patterns call for gender-sensitive policies and interventions. The study further documents a significant role of paediatric HIV on nutritional status, and the potential for community-based paediatic HIV testing to ameliorate this. Targeted early paediatric HIV testing of exposed or at risk children, followed by appropriate health care for infected children, may improve their nutritional status and survival.

abstract: Over the past several decades, there has been a growing interest in the use of fluorescent probes in low-cost diagnostic devices for resource-limited environments. This dissertation details the design, development, and deployment of an inexpensive, multiplexed, and quantitative, fluorescence-based lateral flow immunoassay platform, in light of the specific constraints associated with resource-limited settings. This effort grew out of the need to develop a highly sensitive, field-deployable platform to be used as a primary screening and early detection tool for serologic biomarkers for the high-risk human papillomavirus (hrHPV) infection. A hrHPV infection is a precursor for developing high-grade cervical intraepithelial neoplasia (CIN 2/3+). Early detection requires high sensitivity and a low limit-of-detection (LOD). To this end, the developed platform (DxArray) takes advantage of the specificity of immunoassays and the selectivity of fluorescence for early disease detection. The long term goal is to improve the quality of life for several hundred million women globally, at risk of being infected with hrHPV. The developed platform uses fluorescent labels over the gold-standard colorimetric labels in a compact, high-sensitivity lateral flow assay configuration. It is also compatible with POC settings as it substitutes expensive and bulky light sources for LEDs, low-light CMOS cameras, and photomultiplier tubes for photodiodes, in a transillumination architecture, and eliminates the need for expensive focusing/transfer optics. The platform uses high-quality interference filters at less than $1 each, enabling a rugged and robust design suitable for field use. The limit of detection (LOD) of the developed platform is within an order of magnitude of centralized laboratory diagnostic instruments. It enhances the LOD of absorbance or reflectometric and visual readout lateral flow assays by 2 - 3 orders of magnitude. This system could be applied toward any chemical or bioanalytical procedure that requires a high performance at low-cost. The knowledge and techniques developed in this effort is relevant to the community of researchers and industry developers looking to deploy inexpensive, quantitative, and highly sensitive diagnostic devices to resource-limited settings. / Dissertation/Thesis / Doctoral Dissertation Electrical Engineering 2018

Neglected tropical diseases (NTD) in low- and middle-income countries are still not on target per the World Health Organization's (WHO) elimination goal of 2020. Mass drug administration (MDA) is one of the effective strategies supported by the WHO for the control and subsequent elimination of NTD. This quantitative study explored how supply chain logistic capacity may be hampering MDA coverage in countries in which the diseases are endemic. The study examined secondary data from WHO data bank for MDA coverage, to quantify the relationship between supply chain logistics capacity, as measured by the World Bank's logistics performance index (LPIs), and the control of NTD using MDA. The ecological theory of health behavior was the theoretical framework for this study. The research questions explored whether a low- and/or middle-income country's supply chain infrastructure, logistics services, customs and border procedures, and supply chain reliability, predict the coverage of MDA in controlling NTD. A multiple regression model determined the linear relations between each predictor: supply chain infrastructure (H1), logistics services (H2), custom and border procedures (H3), and supply chain reliability (H4) and the control of neglected diseases as determine by MDA. Results indicated that supply chain capacity, custom and border processes, and supply chain reliability are statistically significant in predictors of MDA coverage in the control of NTD in developing countries. This study may enhance social change by improving supply chain capacity for more effective distribution of PCT drugs, thus helping with the elimination of NTDs and improved health outcomes in low- and middle-income countries.

La Couverture Santé Universelle (CSU) vise permettre à chaque individu d’utiliser les services de santé dont il a besoin sans risque de ruine financière ou d’appauvrissement. Bien que le concept de CSU offre un cadre directeur important pour une nation, tous les pays, quel que soit leur niveau de revenu, sont aux prises avec la réalisation ou le maintien de la couverture universelle. Dans ce contexte, générer des preuves sur les expériences des pays et partager les leçons sur les principales contraintes et les choix stratégiques utilisés pour surmonter les barrières techniques serait susceptible de permettre aux pays à revenus faibles ou intermédiaires d’aller de l'avant et de progresser plus rapidement vers la CSU. La thèse propose une analyse comparative de plusieurs instruments politiques, utilisés par cinq cas pays (Niger, Vietnam, Bangladesh, Gabon, France), pour étendre la couverture sanitaire et la protection financière. L’analyse montre que les interventions simples, comme la suppression des frais des utilisateurs (Niger) ou de l'assurance santé à base communautaire (Bangladesh), peuvent accroître l'utilisation des services pour les groupes les plus défavorisés, mais font face à de fortes limitations dans l’atteinte de plus grandes ambitions. Des réformes plus articulées ont démontré des gains importants dans le développement de la couverture santé, mais font également face à des défis pour trouver l'espace budgétaire suffisant (Gabon) et améliorer l’efficience et l'équité du système (Vietnam). Enfin, la thèse analyse les effets de différentes réformes utilisées pour maintenir les gains de la CSU dans des systèmes de santé mûrs, tel que la France. Dans l'ensemble, la thèse a démontré que le menu des réformes vers la couverture universelle est vaste, complexe et perpétuel mais que certains chemins peuvent conduire au succès. / Universal Health Coverage (UHC) is to ensure that everyone can use the health services they need without risk of financial ruin or impoverishment. While the UHC concept offers a powerful framework for a nation, all countries, irrespective of their income level, are struggling with achieving or sustaining universal coverage. In this context, generating evidence about countries’ experiences and sharing lessons on key constraints and strategic choices used to overcome technical barriers would likely enable low-and-middle countries to move forward and make faster progress toward UHC. The thesis provides a comparative analysis of policy instruments used by five selected country cases (Niger, Vietnam,Bangladesh, Gabon and France), to expand health coverage and financial coverage. Analysis shows that single interventions, like user fee removal (Niger) or community-based insurance (Bangladesh), can increase service utilization for the most disadvantaged groups but face strong limitations toward greater ambitions. More articulated reforms have demonstrated significant gains in expanding health coverage but also face challenges in finding the adequate fiscal space (Gabon) and in strengthening system’s efficiency and equity (Vietnam). Finally, the thesis analyzed the effects of different reforms used to sustain gains of UHC in mature health systems, like France. Overall, the thesis demonstrated that the reform agenda for universal coverage is large, complex and perpetual but that certain pathways can ensure success.

Aquesta recerca es va desenvolupar al Perú, país d'economia emergent i de renda mitjana-alta. Si bé té un creixement econòmic sostingut, els seus indicadors de pobresa no disminueixen al ritme del seu creixement i el seu nivell d'iniquitat econòmica continua essent un dels més elevats de l'Amèrica Llatina. L'objectiu d'aquesta recerca és comprendre i explicar la relació que s'estableix entre les empreses i les famílies que incentiven la reducció de la pobresa en l'àmbit rural. Els resultats contribueixen a entendre l'aportació que el sector privat pot fer en la reducció de la pobresa rural. La recerca s'ha fet d'acord amb el mètode qualitatiu, basat en l'estudi de quatre casos, de dues empreses financeres: la Financiera Confianza i la Caja Municipal de Ahorro y Crédito del Cusco, i de dues empreses extractives: la Minera Yanacocha i el Grupo Energético Aguaytía. El marc conceptual sobre la responsabilitat social s'ha basat en les teories d'Archie B. Carroll, Michael Porter i Mark Kramer, els quals identifiquen quatre tipus de relacions: econòmica, legal, ètica i filantròpica. I en tres teories endògenes sobre la reducció de la pobresa: la capitalització dels actius físics de la població pobra, d'Hernando de Soto; el desenvolupament de les capacitats humanes, d'Amartya Sen, i l'accés als mercats, de C. K. Prahalad, coneguda com el model de la "base de la piràmide" (BOP). D'acord amb les conclusions obtingudes, la relació entre l'empresa i la família ha contribuït efectivament a reduir la pobresa. Dels quatre tipus de relació empresa- família, el tipus de relació preponderant és l'econòmica, seguit de l'ètica i de la filantròpica. A partir de l'anàlisi dels casos, es comprova que les famílies rurals han utilitzat, principalment, dues de les estratègies esmentades per superar la pobresa: l'estratègia d'accés als mercats, enunciada per C. K. Prahalad, i l'estratègia de desenvolupament de capacitats, enunciada per Amartya Sen. L'estratègia de valorització dels actius físics, proposada per De Soto, acompleix una funció en la disminució de la vulnerabilitat social, és a dir, a evitar que les famílies que van superar la pobresa hi tornin a caure. Això confirma el potencial contributiu del sector privat en la reducció de la pobresa rural. / La presente investigación se desarrolló en el Perú, país de economía emergente y de renta media alta. Aún cuando cuenta con un crecimiento económico sostenido, sus indicadores de pobreza no disminuye al ritmo de su crecimiento y su nivel de inequidad economica sigue siendo uno de los más altos en latinoamerica. El propósito de esta investigación es comprender y explicar la relación establecida entre las empresas y las familias que incentivan la reducción de la pobreza en el ámbito rural. Los resultados contribuyen a la comprensión del aporte que puede hacer el sector privado en la reducción de la pobreza rural. La investigación se realizó con el método cualitativo, basado en cuatro estudios de casos; dos empresas financieras: La Financiera Confianza, La Caja Municipal de Ahorro y Crédito del Cusco, y dos empresas extractivas: la Minera Yanacocha y el Grupo Energético Aguaytía. El marco conceptual sobre la responsabilidad social se basó en las teorías de Archie B. Carroll y Michael Porter y Mark Kramer. Quienes han identificado cuatro tipos de relaciones: económica, legal, ética y filantrópica. Y tres teorías endógenas sobre la reducción de la pobreza; la capitalización de los activos físicos de la población pobre de Hernando de Soto; el desarrollo de las capacidades humanas de Amartya Sen, y el acceso a los mercado de C.K. Prahalad, conocida como el modelo de la Base de la Pirámide, BOP. Según los hallazgos la relación entre la empresa y la familia ha contribuido efectivamente en la reducción de la pobreza. De los cuatro tipos de relación Empresa-Familia; el tipo de relación preponderante es la económica, seguido del tipo de relación ética, y la relación filantrópica. De acuerdo con el análisis de los casos, se comprueba que las familias rurales han utilizado, principalmente dos de las estrategias mencionadas para superar su pobreza; la estrategia de acceso a los mercados, enunciada por C. K. Prahalad, y la estrategia de desarrollo de capacidades, enunciada por Amartya Sen. La estrategia de valorización de activos físicos, propuesta por De Soto, cumple una función en la disminución de la vulnerabilidad social, es decir en evitar que las familias que superaron la pobreza vuelvan a caer en ella. Confirmando de esta manera el potencial contributivo del sector privado en la reducción de la pobreza rural. / This research was undertaken in Peru. Peru is a country with an emerging economy, growing at an average annual rate of 7% per annum, and middle income country. Nevertheless, its poverty and economic inequality indicators are among the highest in Latin America. The aim of this research is to understand and explain those relationships established between business and families that promote poverty reduction in rural areas. This research was developed using a qualitative method based on four case studies; two finance companies: Financiera Confianza, Caja Municipal de Ahorro y Crédito del Cusco and two extractive companies: Yanacocha Mining Company, Aguaytia Energy Group. The conceptual framework relating to social responsibility is based on the theories of Archie B. Carroll, Michael Porter and Mark Kramer, who recognize four kinds of relationships between business and families: economic, legal, ethical and philanthropic. In addition, they acknowledge three endogenous theories of poverty reduction: Hernando de Soto's theory of asset capitalization of the impoverished, the human capability development of Amartya Sen, and C.K. Prahalad's market access theory, known as the Base of the Pyramid model (BOP.) The findings of this research demonstrated that the relationship between business and families has contributed to poverty reduction in rural areas. Of the four kinds of relationships, the economic type predominated, followed by the ethic and philanthropic relationships. According to the case analyses, the participating rural families primarily employed two strategies in order to overcome their poverty: the market access model of C.K. Prahalad and Sen's capabilitiy development strategy. Furthermore, the asset capitalization theory of De Soto contributed to decreases in social vulnerability; that is to say, it helps ensure that rural families do not return to poverty. These outcomes confirm the strength of the private sector's contribution to rural poverty reduction.

Introduction: The burden of road traffic injuries (RTI) is worsening globally, particularly in low- and middle-income countries (LMIC) and among the young and economically productive populations. A major barrier to improving road safety in India and other LMIC is that existing RTI data sources are severely limited by poor population coverage and data quality. This dissertation explores the reliability and feasibility of using a novel data source with verbal autopsy (VA) methods for the purposes of RTI surveillance in India. Methods: The reliability of the VA methods was assessed using physician agreement on the specific categories of injury death as the metric. Next, a nationally representative household mortality survey with VA methods was used to directly estimate the age- and gender-specific RTI death rates and to identify context-specific RTI risk factors in India. Finally, a national spatial database was constructed to quantify potential access to trauma care in relation to the spatial distribution of RTI deaths in India. Results: Across a broad array of application settings in India, the level of physician agreement was high indicating that the VA methods were reliable in distinguishing RTI deaths among other specific categories of injury deaths. The estimated 183,600 RTI deaths in 2005 from the mortality survey were over 50% more than the national police statistics. Of these RTI deaths, 65% were males between ages 15-59 years, 68% were pedestrians and other vulnerable road users, and over 55% occurred at the scene of collision, within minutes of collision, and/or involved a head injury. The existing community health centres and district hospitals in the Indian public health system had inadequate trauma care capacity but were suitably located to allow broad spatial access to timely trauma care for the majority of RTI deaths in India, which were most problematic in the northern states of Punjab, Haryana, Himachal Pradesh and in Tamil Nadu. Conclusions: Properly designed VA studies can provide accurate and reliable RTI surveillance data and assist in identifying context-specific road safety interventions.