Aga Khan University Nairobi

Background Global concern exists for workplace violence against healthcare workers (HCWs), especially in low and middle-income nations. This violence includes physical, verbal, or sexual abuse and has a significant impact despite initiatives like Occupational Safety and Health Administration (OSHA) guidelines. We conducted a study in Kenya to address this issue. Methods We did a cross-sectional survey that collected responses during June 6th to August 9th, 2022, focused on healthcare professionals in Kenya within the global ViSHWaS study. Violence against healthcare professionals in multiple Kenyan counties was analysed, The study reached participants through social media, emails, and other channels using a snowball sampling technique. Results The survey included 1,458 HCWs, primarily females (66.5%), aged 36–45 (42.4%), and of African race, representing 40 counties, with the majority from Nairobi (28.9%) and working in government academic (35.5%) and private academic institutions (20.6%). Most had over 11 years of healthcare experience (64.4%), and registered nurses were the most common cadre (27.8%). Approximately half of enrolled participants (49.9%) reported experiencing violence, with verbal violence (80.6%) and emotional abuse (78.6%) being common. Online harassment was reported by only 3.5%, mainly on Facebook (63.2%), involving hate speech (92.1%). Patients or their relatives were the most common aggressors (44.7%), while supervisors accounted for 12.5%. The frequency of violence varied, and 80.2% noted an increase after the COVID-19 pandemic. Only 41.2% of incidents were reported. Most were familiar with safety guidelines (93.6%). Self-violence was associated with familiarity with guidelines, concern about violence, preparedness, and night shifts, while colleague violence was associated with age, gender, race, work experience, training, preparedness, and night shifts. Conclusion Our Kenya-based cross-sectional sub-analysis highlights that a significant number of HCWs experienced violence, especially during the COVID-19 pandemic, which negatively affected job satisfaction. Although most HCWs were familiar with OSHA guidelines, there were difficulties in their practical implementation.

Purpose of Review This narrative review aims to synthesize global literature on the relationship between cardiovascular diseases (CVD) and components of built environment (green spaces, walkability, food environment, accessibility and availability of recreational and healthcare facilities, and effects of air and noise pollution). Recent Findings Increased green space and neighborhood walkability are associated with lower CVD mortality and morbidity; however, benefits have shown differential effects by socioeconomic status (SES). Air pollution is a leading environmental risk factor contributing to CVDs, and it disproportionately impacts low SES populations and women. Findings on relationships between food environment and CVDs are inconsistent and limited. Summary This global review reports on the multifactorial and complex relationship between built environment and higher CVD risk and poor CVD outcomes. Future research can address an unmet need to understand this relationship with further depth and breadth, and to investigate resulting health disparities.

Introduction Dual Antiplatelet Therapy (DAPT) plays an important role in the secondary prevention of ischemic events after treatment for acute coronary syndrome (ACS). The long-term use of DAPT is associated with an increased risk of bleeding, which affects morbidity and mortality. Risk stratification scores have been developed to predict this risk and provide a balance against the risk of ischemic events. The aim of this study was to determine the incidence of bleeding in a cohort of patients in Kenya on DAPT and assess the performance of the PRECISE-DAPT Score in predicting the risk of bleeding. Methods This was a retrospective study conducted in three hospitals in Kenya among patients on DAPT after ACS between January 2019 and April 2022. We reviewed medical records for demographic and clinical characteristics and conducted telephone interviews to assess bleeding for patients on DAPT for a minimum period of one year. Bleeding events were categorized according to the TIMI criteria for bleeding, and the PRECISE-DAPT Score was calculated using an online calculator. The cumulative one-year incidence of bleeding was calculated and presented as frequencies and percentages. Receiver operating characteristic (ROC) analysis and C-statistics were used to quantify the ability of the PRECISE-DAPT Score to predict bleeding events, whereas calibration was estimated using the Hosmer‒Lemeshow goodness-of-fit test. Results A total of 202 patients were enrolled in the study. The study population was predominantly male (n = 156, 77.2%) and African (n = 141, 69.8%), with a median age of 61 years (IQR 52–72). Majority were admitted with ST-Elevation Myocardial infarction (STEMI) (n = 126, 62.4%) and had a mildly reduced left ventricle ejection fraction (n = 124, 61.4%). Fourteen patients (6.9%) met the TIMI criteria for bleeding, of whom 11 (5.4%) had minimal bleeding and 3 (1.5%) had minor bleeding. There was no incidence of major bleeding. The discrimination and calibration of the PRECISE-DAPT Score was good {ROC curve 0.699 (95% CI: 0.564–0.835)} and the Hosmer–Lemeshow goodness-of-fit test (Chi-square, 6.53; p = 0.588), respectively. Conclusion The incidence of bleeding was low, with the majority of patients having minimal bleeding that did not require medical intervention. The PRECISE-DAPT Score performed well in predicting bleeding in patients on DAPT.

Purpose Previous research, largely from the Global North, reports high rates of common mental health disorders among women in the antenatal period, but there is paucity of such data in contexts like Kenya. This study investigated the prevalence and correlates of depressive and anxiety symptoms among pregnant women in an urban informal settlement in Kenya’s capital – Nairobi. Methods An analysis of baseline cross-sectional data from a pilot cluster randomized trial of an integrated early childhood development programme. Participants were pregnant women in their third pregnancy trimester (N = 249), residing in an urban informal settlement in Nairobi County. Mental health measures [(Patient health questionnaire (PHQ-9) and generalized anxiety disorder scale (GAD-7)] were administered alongside other sociodemographic, pregnancy, and health-related questionnaires. Linear regression analysis was performed to investigate correlates of antenatal depressive and anxiety symptoms. Results Participant’s mean age was 27.5 years (SD = 5.6). The prevalence of antenatal depressive and anxiety symptoms was 26.9% (95%CI: 21.4–32.4) and 6.4% (95%CI: 3.4–9.4), based on the PHQ-9 and GAD-7 cut-off scores of ≥ 10 respectively. Being married was a significant correlate for decreased depressive and anxiety symptoms. Higher levels of education (secondary or tertiary), history of three or more previous pregnancies, and an experience of moderate-to-extreme pain were significant correlates for elevated depressive symptoms. Similarly, tertiary level of education, history of four or more previous pregnancies, and experiencing pain were significant correlates for elevated anxiety symptoms for the pregnant women. Participants reporting feeling unwell had significantly higher anxiety symptom scores. Conclusion In this setting, correlates of antenatal depressive and anxiety symptoms cut across demographic, pregnancy and health-related factors with implications for targeted interventions. Findings point to the need for screening of depression and anxiety as part of routine antenatal care. Further research is needed to understand these contextual correlates. Trial registration This study was part of the integrated early childhood development pilot cluster randomised control trial, retrospectively registered in the Pan African Clinical Trial Registry on 26/03/2021, registration number PACTR202103514565914.

Background Approximately half of all antimicrobial prescriptions in intensive care units (ICUs) may be inappropriate, including those prescribed when not needed, in unnecessary combinations or for longer durations than needed. Inappropriate prescribing is costly, exposes patients to unnecessary side-effects and drives population-level antimicrobial resistance, the prevalence and consequences of which are greatest in low- and middle-income countries. However, the implementation of interventions to improve the appropriateness of antimicrobial prescribing has been variable and requires further study. Methods We propose a type III hybrid implementation/effectiveness interventional cohort trial in 35 ICUs in up to 11 low- and middle- income countries. The study intervention is a structured review of antimicrobial prescriptions as recommended by the World Health Organisation. Strategies to support stakeholder-led implementation include development of local protocols, registry-enabled audit and feedback, and education. Evaluation of implementation, and the determinants of its success, is informed by the RE-AIM framework and the Consolidated Framework for Implementation Research respectively. The primary outcome is a composite measure of fidelity, reach and adoption. Secondary outcomes describe the effectiveness of the intervention on improving antimicrobial prescribing. Qualitative interviews will assess relevant implementation acceptability, adaptations and maintenance. A baseline survey will investigate ICU-level antimicrobial stewardship structures and processes. Discussion This study addresses global policy priorities by supporting implementation research of antimicrobial stewardship, and strengthening associated healthcare professional competencies. It does this in a setting where improvement is sorely needed: low- and middle- income country ICUs. The study will also describe the influence of pre-existing antimicrobial stewardship structures and processes on implementation and improve understanding about the efficacy of strategies to overcome barriers to implementation in these settings. Trial registration This study protocol has been registered with ClinicalTrials.gov (ref NCT06666738) on 31 Oct 2004. https://clinicaltrials.gov/study/NCT06666738?term=NCT06666738&rank=1.

In 2022, the World Health Organization (WHO) issued the Intersectoral Global Action Plan for Epilepsy and Other Neurological Disorders for 2022 to 2031, emphasizing important connections between brain health, population well‐being, and economic growth. A year later, the WHO followed up with strategic guidelines aimed at enhancing brain health outcomes in developing countries. However, critical gaps remain. Our policy forum paper advocates for policies that target brain health across all stages of life, starting with measures to reduce the consumption of alcohol, sugar, and tobacco. Additionally, we propose the integration of school meal programs and social pension schemes as essential lifespan policies to safeguard brain health. To support these policies, developing countries must implement key macroeconomic reforms. These include revising international trade agreements, strengthening tax systems, curbing illicit financial flows, eliminating financial exclusions, and expanding social welfare systems. Such reforms are critical for creating an environment that supports long‐term brain health initiatives. Highlights The are critical gaps in the WHO policy framework for brain health. We advocate policies that target brain health across all stages of life, starting with measures to reduce alcohol, sugar, and tobacco consumption. Additionally, we propose integrating school meal programs and social pension schemes as essential lifespan policies to safeguard brain health. To support these policies, developing countries must implement key macroeconomic reforms. By adopting these measures, developing countries can lead the charge in advancing the 21st‐century brain health agenda, fostering both societal well‐being and sustainable economic development.

Updates of current and projected estimates of the burden are critical to monitoring the success of ongoing efforts in breast cancer control, such as the World Health Organization Global Breast Cancer Initiative, which aims to reduce breast cancer mortality by 2.5% per year. We investigated the current (2022) and future (2050) global burden of female breast cancer overall, and by age group, in 185 countries using the GLOBOCAN database, and 10-year trends in incidence and mortality rates in 50 and 46 countries, respectively, using the Cancer Incidence in Five Continents plus and World Health Organization mortality databases. Globally, 2.3 million new cases and 670,000 deaths from female breast cancer occurred in 2022. Annual rates increased by 1–5% in half of examined countries. Mortality rates decreased in 29 countries with very high Human Development Index (HDI), and seven countries (for example, Belgium and Denmark) are meeting the Global Breast Cancer Initiative goal of at least a 2.5% decrease each year. By 2050, new cases and deaths will have increased by 38% and 68%, respectively, disproportionately impacting low-HDI countries. High-quality cancer and vital status data, and continued progress in early diagnosis and access to treatment, are needed in countries with low and medium HDI to address inequities and monitor cancer control goals.

Background Virus co-infection or reactivation may modify the host response during cerebral malaria. Cytomegalovirus (CMV) DNAemia has been associated with increased morbidity and mortality in adults with sepsis; however, the impact of CMV DNAemia on adverse outcomes in children with cerebral malaria is unknown. Methods Clinical, physiological, and neurocognitive outcomes were compared in children aged 18 months to 12 years with cerebral malaria (N = 242) based on the presence or absence of CMV DNAemia 24 h after admission. The primary study outcome was subsequent in-hospital mortality. Secondary outcomes included the presence of acute kidney injury, neurocognitive impairment over a 2-year follow-up, and chronic kidney disease at the 1-year follow-up. Markers of platelet and endothelial cell activation and oxidative and nitrosative stress were measured to characterize the mechanisms by which CMV DNAemia might contribute to pathogenesis. Results CMV DNAemia was present in 33 children with cerebral malaria (13.6%) 24 h after admission. CMV DNAemia was not significantly associated with mortality in this study. Children with CMV-DNAemia had a higher prevalence of acute kidney injury than those without CMV-DNAemia (59.4% vs. 38.6%, p = 0.03). There was no difference in the prevalence of chronic kidney disease or long-term neurocognitive impairment based on the presence of DNAemia. CMV DNAemia was associated with elevated plasma levels of P-selectin, angiopoietin-1, asymmetric dimethylarginine, and platelet counts. Conclusions In children with cerebral malaria, CMV DNAemia is associated with acute kidney injury but not in-hospital mortality, chronic kidney disease, or long-term neurocognitive impairment.

Introduction Autophagy is a metabolic process that serves to maintain cellular homeostasis as well as enable the cell to adapt to metabolic stress. In malignant cells, autophagy has been associated with drug resistance, metastasis and poor outcome. Colorectal carcinoma is a leading cause of cancer morbidity and mortality worldwide. The management and outcome are dependent on the tumor clinical and pathological characteristics. Autophagy is a potential therapeutic target as well as prognostic biomarker given its role in cancer pathogenesis. This study aimed at evaluating the autophagy status of colorectal carcinomas for tumors diagnosed at the Aga Khan University Hospital, Nairobi and establish its association with clinical-pathological characteristics including age, tumor location, tumor grade, tumor pathological stage, tumor nodal stage, tumor budding, tumor-infiltrating lymphocytes (TILs), Mismatch repair protein status (MMR), HER2 status and patient survival. Methods The study assessed the autophagy status of 114 colorectal carcinoma cases using immunohistochemistry for autophagy related protein LC3β. The clinical-pathological characteristics were determined by examining the medical records and evaluation of hematoxylin and eosin-stained slides. HER2 and MMR status were evaluated using immunohistochemistry. The treatment outcome was determined from the patient's records by checking for date of last visit or death. Results and discussion The mean age of patients in our study was 58years. There were more males 61.8% (n = 70) than females 38.6% (n = 44). Most of the patients had high pathological tumor stage of pT3 and pT4. Majority of the tumors showed intermediate tumor budding and weak tumor-infiltrating lymphocytes. The mismatch repair deficiency and HER2 overexpression were found in 14.9% (n = 17) and 2.6% (n = 3) of the cases respectively. LC3β was overexpressed in 36% (n = 41) of the cases and was significantly more common in females (p = 0.013). The LC3β status showed no significant association with age, tumor location, tumor grade, tumor stage, nodal stage, tumor budding, tumor-infiltrating lymphocytes, MMR status, HER2 status or patient survival. Future prospective studies are recommended to further explore the utility of autophagy as a prognostic and predictive biomarker.

Objectives Approximately 80% of people with epilepsy live in low- and middle-income countries (LMICs), where limited resources and stigma hinder accurate diagnosis and treatment. Clinical machine learning models have demonstrated substantial promise in supporting the diagnostic process in LMICs by aiding in preliminary screening and detection of possible epilepsy cases without relying on specialised or trained personnel. How well these models generalise to naïve regions is, however, underexplored. Here, we use a novel approach to assess the suitability and applicability of such clinical tools to aid screening and diagnosis of active convulsive epilepsy in settings beyond their original training contexts. Methods We sourced data from the Study of Epidemiology of Epilepsy in Demographic Sites dataset, which includes demographic information and clinical variables related to diagnosing epilepsy across five sub-Saharan African sites. For each site, we developed a region-specific (single-site) predictive model for epilepsy and assessed its performance at other sites. We then iteratively added sites to a multi-site model and evaluated model performance on the omitted regions. Model performances and parameters were then compared across every permutation of sites. We used a leave-one-site-out cross-validation analysis to assess the impact of incorporating individual site data in the model. Results Single-site clinical models performed well within their own regions, but generally worse when evaluated in other regions (p<0.05). Model weights and optimal thresholds varied markedly across sites. When the models were trained using data from an increasing number of sites, mean internal performance decreased while external performance improved. Conclusions Clinical models for epilepsy diagnosis in LMICs demonstrate characteristic traits of ML models, such as limited generalisability and a trade-off between internal and external performance. The relationship between predictors and model outcomes also varies across sites, suggesting the need to update specific model aspects with local data before broader implementation. Variations are likely to be particular to the cultural context of diagnosis. We recommend developing models adapted to the cultures and contexts of their intended deployment and caution against deploying region- and culture-naïve models without thorough prior evaluation.

Introduction Air pollution is linked with poor neurodevelopment in high-income countries. Comparable data are scant for low-income countries, where exposures are higher. Longitudinal pregnancy cohort studies are optimal for individual exposure assessment during critical windows of brain development and examination of neurodevelopment. This study aims to determine the association between prenatal ambient air pollutant exposure and neurodevelopment in children aged 12, 24 and 36 months through a collaborative, capacity-enriching research partnership. Methods and analysis This observational cohort study is based in Nairobi, Kenya. Eligibility criteria are singleton pregnancy, no severe pregnancy complications and maternal age 18 to 40 years. At entry, mothers (n=400) are administered surveys to characterise air pollution exposures reflecting household features and occupational activities and provide blood (for lead analysis) and urine specimens (for polycyclic aromatic hydrocarbon (PAH) metabolites). Mothers attend up to two additional antenatal study visits, with urine collection, and infants are followed through age 36 months for annual neurodevelopment and caregiving behaviour assessment, and child urine and blood collection. Primary outcomes are child motor skills, language and cognition at 12, 24 and 36 months, and executive function at 36 months. The primary exposure is urinary PAH metabolite concentrations. Additional exposure assessment in a subset of the cohort includes residential indoor and outdoor air monitoring for fine particulate matter (PM2.5), carbon monoxide (CO), ultrafine particles (UFP) and black carbon (BC). Ethics and dissemination This study was approved by the Kenyatta National Hospital - University of Nairobi Ethics and Research Committee, and the University of Washington Human Subjects Division. Results are shared at annual workshops.

In this article we reflect on the state of family medicine education and training in sub-Saharan Africa; in particular, we focus on these key issues: advocacy, evidence of impact, barriers and enablers, and implementation strategies. Sub-Saharan Africa is the last region of the world to embrace family medicine, and adoption varies widely among countries. Family physicians with postgraduate training are relatively few. In the public sector, primary care is mostly offered by nurses or physician assistants, while in the private sector, it is offered by general practitioners. Family physicians work in both primary care and primary hospitals, in multidisciplinary teams; as clinicians, consultants, capacity builders, clinical trainers, leaders of clinical governance and may also have some managerial functions. Advocacy for the contribution of family physicians and training programs is needed with departments of health, regulatory bodies, higher education institutions, and other health professions. Evidence of impact in the African context is limited due to the small numbers and limited research outputs. Barriers and enablers to education and training are related to the stage of development. Key issues include a lack of academic and teaching expertise, a need to develop learning environments and clinical trainers, sufficient training posts, and appropriate deployment of new graduates. Implementation strategies to overcome these barriers can be categorized into planning, educational, financial, quality management, and policy related strategies. A South-South-North approach to support and partnerships is advocated. More attention should be given to engaging the public on the contribution of family medicine.

Background & Aims This study used the Global Burden of Disease data (2010–2021) to analyze the rates and trends of point prevalence, annual incidence, and years lived with disability (YLDs) for metabolic dysfunction-associated steatotic liver disease (MASLD) in 204 countries. Methods Total numbers and age-standardized rates per 100,000 population for MASLD prevalence, annual incidence, and YLDs were compared across regions and countries by age, sex, and sociodemographic index (SDI). Smoothing spline models were used to evaluate the relationship between the burden of MASLD and SDI. Estimates were reported with uncertainty intervals (UI). Results Globally, in 2021, the age-standardized rates per 100,000 population of point prevalence of MASLD were 15,018.1 cases (95% UI 13,756.5–16,361.4), annual incidence rates were 608.5 cases (598.8–617.7), and YLDs were 0.5 (0.3–0.8) years. MASLD point prevalence was higher in men than women (15,731.4 vs. 14,310.6 cases per 100,000 population). Prevalence peaked at ages 45–49 for men and 50–54 for women. Kuwait (32,312.2 cases per 100,000 people; 95% UI: 29,947.1–34,839.0), Egypt (31,668.8 cases per 100,000 people; 95% UI: 29,272.5–34,224.7), and Qatar (31,327.5 cases per 100,000 people; 95% UI: 29,078.5–33,790.9) had the highest prevalence rates in 2021. The largest increases in age-standardized point prevalence estimates from 2010 to 2021 were in China (16.9%, 95% UI 14.7%–18.9%), Sudan (13.3%, 95% UI 9.8%–16.7%) and India (13.2%, 95% UI 12.0%–14.4%). MASLD incidence varied with SDI, peaking at moderate SDI levels. Conclusions MASLD is a global health concern, with the highest prevalence reported in Kuwait, Egypt, and Qatar. Raising awareness about risk factors and prevention is essential in every country, especially in China, Sudan and India, where disease incidence and prevalence are rapidly increasing. Impact and implications This research provides a comprehensive analysis of the global burden of MASLD, highlighting its rising prevalence and incidence, particularly in countries with varying sociodemographic indices. The findings are significant for both clinicians and policymakers, as they offer critical insights into the regional disparities in MASLD burden, which can inform targeted prevention and intervention strategies. However, the study’s reliance on modeling and available data suggests cautious interpretation, and further research is needed to validate these findings in clinical and real-world settings.

The objective of this study is to develop evidence-based recommendations for the diagnosis and management of enthesitis-related arthritis (ERA) and juvenile psoriatic arthritis (JPsA) in the African context. The recommendations for ERA and JPsA were combined into a single document. The steering committee and task force identified 15 key questions and formulated 35 research questions. A comprehensive literature review, utilizing Medline and a manual search for African local data, was conducted to gather evidence. Following this synthesis, the task force developed draft recommendations and engaged in a Delphi process with an expert panel, including 17 African and three international experts, to reach a consensus and ensure alignment with global standards. The final recommendations were assigned a level of evidence and subsequently approved by the task force members, the expert panel, and the PAFLAR Board. Fifteen recommendations on the diagnosis and management of ERA and JPsA were developed, covering the role of the pediatric rheumatologist in multiple aspects of disease management, including diagnosis, monitoring of disease and extra-articular manifestations, determining treatment strategies, and guiding interventions. The level of evidence supporting these recommendations was variable, leading to the identification of a research agenda to address African particularities and answer pending questions. The final recommendations achieved a high level of agreement, with consensus ranging from 90 to 100%. These recommendations represent an important achievement for pediatric rheumatology in Africa, being the first of their kind, tailored specifically to the region. Developed through a rigorous methodology and collaboration between international and African experts, they aim to standardize care and address the unique challenges faced in African setting.

The eligibility criteria for social pension schemes in Africa hinder equitable and healthy aging. In 2019, women in 14 sub‐Saharan African countries had an average life expectancy of 67 years but a healthy life expectancy of only 57 years, leaving them 5 years in poor health before receiving a pension at age 62. Men had a similar situation—a life expectancy of 62 years and a healthy life expectancy of 53 years, spending 10 years in poor health before becoming eligible for pensions at age 63. Many men do not receive pensions due to early death. Delays and low pension payouts contribute to a 2.5% increase in the death rate from Alzheimer's disease and dementia. Highlights Eligibility criteria for social pension schemes in Africa hinder equitable and healthy aging. Delays and low pension payouts are associated with worsening death rates from dementia. Average health life expectancy for both genders should serve as a basis for initiating pension payouts.

Introduction Self-harm represents a complex and multifaceted public health issue of global significance, exerting profound effects on individuals and communities alike. It involves intentional self-poisoning or self-injury with or without the motivation to die. Although self-harm is highly prevalent, limited research has focused on the patterns and trends of self-harm among hospital populations in low- and middle-income countries, particularly within Africa. This study aims to explore the socio-demographic and clinical profile of patients presenting with self-harm and determine the common self-harm patterns at a tertiary facility in Kenya. Methodology We carried out a descriptive retrospective study and included patients from inpatient units and outpatient settings within the Secion of Psychiatry at the Aga Khan University Hospital, Nairobi from January 1st 2018 to December 31st 2022. A data abstraction tool was used to collect data from eligible files sourced from the medical records department for all patients who met the study criteria. Summary statistics were reported as frequencies and percentages for categorical data and as means and standard deviations for continuous data. Results A total of 507 files were reviewed in the given timeframe and 497 patients were included in the analysis. Of these patients, 28.1% (n = 144) presented with self-harm. The mean age of the self-harm patients was 26.5 years (SD = 10.5) and a majority (74.3%) were female. The first point-of-contact was at the emergency department in 72.9% of the cases. A majority of them, i.e. 89.6%, reported a past psychiatric diagnosis. Based on the psychiatric diagnosis evaluation of the patients- depression was the most common diagnosis at 88.2%, followed by anxiety disorder at 27.8% and bipolar mood disorder at 17.4%. The majority of reported self-harm cases involved overdose incidents (68.8%), with self-injury accounting for 56.3% of cases. Analgesics were the most frequently reported type of overdose, followed by tricyclic antidepressants. In context of self-injury, cutting emerged as the predominant form of self-harm. Family conflict was reported to be the most common reason for self-harm at 39.6%. Conclusion This study shows a high rate of self-harm among patients with mental illness in this facility, necessitating the development of self-harm prevention and management protocols. A national registry of self-harm behavior would also help further elucidate the occurrence and mechanisms of self-harm in the population, improving the possibility for early interventions and prevention.