Road safety in low- and middle-income countries: a neglected research area

Reducing the incidence and mortality of traumatic brain injury in Latin America

Traumatic brain injury (TBI) represents a considerable portion of the global injury burden. The incidence of TBI will continue to increase in view of an increase in population density, an aging population, and the increased use of motor vehicles, motorcycles, and bicycles. The most common causes of TBI are falls and road traffic injuries. Deaths related to road traffic injury are three times higher in low-and middle-income countries (LMIC) than in high-income countries (HIC). The Latin American Caribbean region has the highest incidence of TBI worldwide, primarily caused by road traffic injuries. Data from HIC indicates that road traffic injuries can be successfully prevented through concerted efforts at the national level, with coordinated and multisector responses to the problem. Such actions require implementation of proven measures to address the safety of road users and the vehicles themselves, road infrastructure, and post-crash care. In this review, we focus on the epidemiology of TBI in Latin America and the implementation of solutions and preventive measures to decrease mortality and long-term disability.

Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs.

METHODS

A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively.

RESULTS

A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified.

CONCLUSIONS

Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.

Generating consensus on road safety issues and priorities in Ghana: A modified Delphi approach

BACKGROUND

Implementation of evidence-based approaches to reduce the substantial health, social, and financial burdens of road traffic injuries and deaths in Ghana and other low-and-middle-income countries (LMICs) is vitally important. Consensus from national stakeholders can provide insight into what evidence to generate and which interventions to prioritize for road safety. The main objective of this study was to elicit expert views on the barriers to reaching international and national road safety targets, the gaps in national-level research, implementation, and evaluation, and the future action priorities.

MATERIALS AND METHODS

We used an iterative three-round modified Delphi process to generate consensus among Ghanaian road safety stakeholders. We defined consensus as 70% or more stakeholders selecting a specific response in the survey. We defined partial consensus (termed "majority") as 50% or more stakeholders selecting a particular response.

RESULTS

Twenty-three stakeholders from different sectors participated. Experts generated consensus on barriers to road safety goals, including the poor regulation of commercial and public transport vehicles and limited use of technology to monitor and enforce traffic behaviors and laws. Stakeholders agreed that the impact of increasing motorcycle (2- and 3-wheel) use on road traffic injury burden is poorly understood and that it is a priority to evaluate road-user risk factors such as speed, helmet use, driving skills, and distracted driving. One emerging area was the impact of unattended/disabled vehicles along roadways. There was consensus on the need for additional research, implementation, and evaluation efforts of several interventions, including focused treatment of hazardous spots, driver training, road safety education as part of academic curricula, promotion of community involvement in first aid, development of strategically positioned trauma centers, and towing of disabled vehicles.

CONCLUSION

This modified Delphi process with stakeholders from Ghana generated consensus on road safety research, implementation, and evaluation priorities.

Factors Contributing to and Reducing Delays in the Provision of Adequate Care in Ghana: A Qualitative Study of Trauma Care Providers

BACKGROUND

Ghana has a large and growing burden of injury morbidity and mortality. There is a substantial unmet need for trauma surgery, highlighting a need to understand gaps in care.

METHODS

We conducted 8 in-depth interviews with trauma care providers (surgeons, nurses, and specialists) at a large teaching hospital to understand factors that contribute to and reduce delays in the provision of adequate trauma care for severely injured patients. The study aimed to understand whether providers thought factors differed between patients that were enrolled in the National Health Insurance Scheme (NHIS) and those that were not. Findings were presented for the third delay (provision of appropriate care) in the Three Delays Framework.

RESULTS

Key findings included that most factors contributing delays in the provision of adequate care were related to the costs of care, including for diagnostics, medications, and treatment for patients with and without NHIS subscription. Other notable factors included conflicts between providers, resource constraints, and poor coordination of care at the facility. Factors which reduce delays included advocacy by providers and informal processes for prioritizing critical injuries.

CONCLUSION

We recommend facility-level changes including increasing equity in access to trauma and elective surgery through targeted system strengthening efforts (e.g., a scheduled back-up call system for surgeons, anesthetists, other specialists, and nurses; designated operating theatres and staff for emergencies; training of staff), policy changes to simplify the insurance renewal and subscription processes, and future research on the costs and benefits of including diagnostics, medications, and common trauma services into the NHIS benefits package.

Identifying research priorities for road safety in Nepal: a Delphi study

OBJECTIVE

To identify and prioritise the research needed to help Nepali agencies develop an improved road safety system.

DESIGN

Delphi study.

SETTING

Nepal.

PARTICIPANTS

Stakeholders from government institutions, academia, engineering, healthcare and civil society were interviewed to identify knowledge gaps and research questions. Participants then completed two rounds of ranking and a workshop.

RESULTS

A total of 93 participants took part in interviews and two rounds of ranking. Participants were grouped with others sharing expertise relating to each of the five WHO 'pillars' of road safety: (1) road safety management; (2) safer roads; (3) safer vehicles; (4) safer road users and (5) effective postcrash response. Interviews yielded 1019 research suggestions across the five pillars. Two rounds of ranking within expert groups yielded consensus on the important questions for each pillar. A workshop involving all participants then led to the selection of 6 questions considered the most urgent: (1) How can implementing agencies be made more accountable? (2) How should different types of roads, and roads in different geographical locations, be designed to make them safer for all road users? (3) What vehicle fitness factors lead to road traffic crashes? (4) How can the driver licensing system be improved to ensure safer drivers? (5) What factors lead to public vehicle crashes and how can they be addressed? and (6) What factors affect emergency response services getting to the patient and then getting them to the right hospital in the best possible time?

CONCLUSIONS

The application of the Delphi approach is useful to enable participants representing a range of institutions and expertise to contribute to the identification of road safety research priorities. Outcomes from this study provide Nepali researchers with a greater understanding of the necessary focus for future road safety research.

Evidence From the Decade of Action for Road Safety: A Systematic Review of the Effectiveness of Interventions in Low and Middle-Income Countries

Objectives: To evaluate the effectiveness of road safety interventions in low and middle-income countries (LMICs), considering the principles of systems theory presented in the Global Plan for the Decade of Action for Road Safety.

Methods: We conducted a systematic review according to PRISMA guidelines. We searched for original research studies published during 2011–2019 in the following databases: Medline, Embase, PsycInfo, Scopus, Web of Science, Cochrane library, Global Health Library, ProQuest and TRID. We included studies conducted in LMICs, evaluating the effects of road traffic safety interventions and reporting health-related outcomes.

Results: Of 12,353 non-duplicate records, we included a total of 33 studies. Most interventions were related to legislation and enforcement (n = 18), leadership (n = 5) and speed management (n = 4). Overall, legislation and enforcement interventions appear to have the largest impact. Few studies were found for road infrastructure, vehicle safety standard and post crash response interventions.

Conclusion: Based on the currently available evidence, legislation and enforcement interventions appear most impactful in LMICs. However, many interventions remain understudied and more holistic approaches capturing the complexity of road transport systems seem desirable.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197267, identifier CRD42020197267.

Drug use and driving behaviors among drivers with and without alcohol-related infractions

INTRODUCTION

Brazil is one of the countries with the highest rates of alcohol-related traffic infractions, but little is known about the profile of the drivers who commit them. Identifying the characteristics of impaired drivers is essential for planning preventive actions.

OBJECTIVE

To compare drug use and driving behavior profiles of drivers with and without alcohol-related infractions.

METHODS

178 drivers stopped at routine roadblocks were assessed by traffic agents who conducted standard roadblock procedures (document verification; request of a breathalyzer test [BT]). Drug use and driving behavior data were collected through semi-structured interviews. Subjects were divided into three groups: drivers who refused the BT (RDs, n = 72), drivers who tested positive on the BT (PDs, n = 34), and drivers who had committed other infractions (ODs, n = 72).

RESULTS

The proportion of alcohol use in the last year was higher among RDs (100%) than in the PD and OD groups (97.1% and 72.2% respectively, p < 0.001). Lifetime prevalence of cannabis and cocaine use for the overall sample was 44.3% and 18.2%, respectively. Fewer individuals in the OD group (31.5%) reported having been stopped at roadblocks in the previous year compared to the PDs (55.9%) and RDs (48.6%, p = 0.03). However, a higher proportion of RDs reported drunk driving in the same period (87.5%; PD 69.7%; OD 26.9%; p < 0.001).

CONCLUSION

Essential differences among groups were observed. RDs had a higher proportion of alcohol use and drunk driving in the previous year; drivers who fit into this particular group may be unresponsive or less responsive to social deterrence and enforcement actions.

Road Safety in Low-Income Countries: State of Knowledge and Future Directions

Road safety in low-income countries (LICs) remains a major concern. Given the expected increase in traffic exposure due to the relatively rapid motorisation of transport in LICs, it is imperative to better understand the underlying mechanisms of road safety. This in turn will allow for planning cost-effective road safety improvement programs in a timely manner. With the general aim of improving road safety in LICs, this paper discusses the state of knowledge and proposes a number of future research directions developed from literature reviews and expert elicitation. Our study takes a holistic approach based on the Safe Systems framework and the framework for the UN Decade of Action for Road Safety. We focused mostly on examining the problem from traffic engineering and safety policy standpoints, but also touched upon other sectors, including public health and social sciences. We identified ten focus areas relating to (i) under-reporting; (ii) global best practices; (iii) vulnerable groups; (iv) disabilities; (v) road crash costing; (vi) vehicle safety; (vii) proactive approaches; (viii) data challenges; (ix) social/behavioural aspects; and (x) capacity building. Based on our findings, future research ought to focus on improvement of data systems, understanding the impact of and addressing non-fatal injuries, improving estimates on the economic burden, implementation research to scale up programs and transfer learnings, as well as capacity development. Our recommendations, which relate to both empirical and methodological frontiers, would lead to noteworthy improvements in the way road safety data collection and research is conducted in the context of LICs.

Transport accident mortality in Chile: trends from 2000 to 2012

Abstract The aim of this study is to describe the trends of transport accident mortality in Chile from 2000 to 2012 by year, geographic distribution, gender, age group, and type of accident. Population-based study. Data for transport accident mortality in Chile between 2000 and 2012 were used. The crude and adjusted per region transport accident mortality rates were calculated per 100,000 inhabitants. The annual percentage change (APC) of the rates and relative risks (RR) were calculated. The average transport accident mortality rate (TAMR) in Chile (2000-2012) was 12.2. The rates were greater in men (19.7) than in women (4.8), with a RR of 4.1. The rates were higher in the country's southern zone (15.9), increasing in recent years in the southern zone, with a significant positive APC in the northern and central zones. The Maule region had the highest rate (21.1), although Coquimbo was the region with the most significant APC (2.2%). The highest rate (20.3) was verified in the 25-40 age group. The highest rate (14.3) was recorded in 2008. The most frequent type of accident was pedestrian. In general the APC trends of the rates are increasing significantly. This, added to rapid annual automotive growth, will only exacerbate mortality due to transport accidents.

Road traffic mortality in the Slovak Republic in 1996-2014

OBJECTIVE

Road traffic mortality takes an enormous toll in every society. Transport safety interventions play a crucial role in improving the situation. In the period 1996-2014 several road safety measures, including a complex new road traffic law in 2009, were implemented in the Slovak Republic, introducing stricter conditions for road users. The aim of this study is to describe and analyze the trends in road user mortality in the Slovak Republic in individual age groups by sex during the study period 1996-2014.

METHODS

Data on overall mortality in the Slovak Republic for the period 1996-2014 were obtained from the Statistical Office of the Slovak Republic. Mortality rates were age-adjusted to the European standard population. Joinpoint regression was used to assess the statistical significance of change in time trends of calculated standardized mortality rates.

RESULTS

Mortality rates of all types of road users as well as all age groups and both sexes in the Slovak Republic in the period 1996-2014 are decreasing. The male : female ratio decreased from 4:1 in 1996 to 2:1 in 2014. Motor vehicle users (other than motorcyclists) and pedestrians have the highest mortality rates among road user groups. Both of these groups show a significant decline in mortality rates over the study period. Within the age groups, people age 65 years and over have the highest mortality rates, followed by the age groups 25-64 and 15-24 years old. Joinpoint regression confirmed a steady, significant decline in all mortality rates over the study period. A statistically significant decrease in mortality rates in the last years of the study period was observed in the age group 25-64 and in male motorcycle users. Assessing the impact of the 2009 road traffic law, a drop was observed in the average standardized mortality rate of all road traffic users from 14.56 per 100,000 person years in the period 1996-2008 to 7.69 per 100,000 person years in the period 2009-2014. A similar drop in the average standardized mortality rate was observed in all individual road user groups.

CONCLUSIONS

The implementation of the new traffic regulations may have contributed significantly to the observed decrease in mortality rates of road users in the Slovak Republic. A significant decrease in mortality was observed in all population groups and in all groups of road users. The introduction of a new comprehensive road traffic law may have expedited the decrease of road fatalities, especially in the age group 25-64 years old. This type of evidence-based epidemiology data can be used for improved targeting of future public health measures for road traffic injury prevention.

Evidence gaps in the global decade of road traffic safety

Road traffic accidents are a leading cause of global mortality. In March 2010, the United Nations General Assembly and the World Health Organization (WHO) officially proclaimed 2011-2020 as the "Decade of Action for Road Safety." Researchers must focus on vulnerable road users and low- and middle-income countries (LMICs) and should give preference to simple high-impact interventions likely to be inexpensive and widely applicable. Collaborative investigative networks should include LMICs, and economic evaluations should demonstrate the value of novel interventions in LMIC settings. Reliable data systems are essential to understand needs and outcomes, and knowledge translation studies should support effective implementation.

Large-scale road safety programmes in low- and middle-income countries: an opportunity to generate evidence

The growing burden of road traffic injuries, which kill over 1.2 million people yearly, falls mostly on low- and middle-income countries (LMICs). Despite this, evidence generation on the effectiveness of road safety interventions in LMIC settings remains scarce. This paper explores a scientific approach for evaluating road safety programmes in LMICs and introduces such a road safety multi-country initiative, the Road Safety in 10 Countries Project (RS-10). By building on existing evaluation frameworks, we develop a scientific approach for evaluating large-scale road safety programmes in LMIC settings. This also draws on '13 lessons' of large-scale programme evaluation: defining the evaluation scope; selecting study sites; maintaining objectivity; developing an impact model; utilising multiple data sources; using multiple analytic techniques; maximising external validity; ensuring an appropriate time frame; the importance of flexibility and a stepwise approach; continuous monitoring; providing feedback to implementers, policy-makers; promoting the uptake of evaluation results; and understanding evaluation costs. The use of relatively new approaches for evaluation of real-world programmes allows for the production of relevant knowledge. The RS-10 project affords an important opportunity to scientifically test these approaches for a real-world, large-scale road safety evaluation and generate new knowledge for the field of road safety.

Sobriety checkpoints in Thailand: a review of effectiveness and developments over time

This review describes the legal basis for and implementation of sobriety checkpoints in Thailand and identifies factors that influenced their historical development and effectiveness. The first alcohol and traffic injury control law in Thailand was implemented in 1934. The 0.05 g/100 mL blood alcohol concentration limit was set in 1994. Currently, 3 types of sobriety checkpoints are used: general police checkpoints, selective breath testing, and special event sobriety checkpoints. The authors found few reports on the strategies, frequencies, and outcomes for any of these types of checkpoints, despite Thailand having devoted many resources to their implementation. In Thailand and other low-middle income countries, it is necessary to address the country-specific barriers to successful enforcement (including political and logistical issues, lack of equipment, and absence of other supportive alcohol harm reduction measures) before sobriety checkpoints can be expected to be as effective as reported in high-income countries.

Reducing the legal blood alcohol concentration limit for driving in developing countries: a time for change? Results and implications derived from a time-series analysis (2001-10) conducted in Brazil

AIMS

In Brazil, a new law introduced in 2008 has lowered the blood alcohol concentration limit for drivers from 0.06 to 0.02, but the effectiveness in reducing traffic accidents remains uncertain. This study evaluated the effects of this enactment on road traffic injuries and fatalities.

DESIGN

Time-series analysis using autoregressive integrated moving average (ARIMA) modelling.

SETTING

State and capital of São Paulo, Brazil.

PARTICIPANTS

  A total of 1,471,087 non-fatal and 51,561 fatal road traffic accident cases in both regions.

MEASUREMENTS

Monthly rates of traffic injuries and fatalities per 100,000 inhabitants from January 2001 to June 2010.

FINDINGS

The new traffic law was responsible for significant reductions in traffic injury and fatality rates in both localities (P<0.05). A stronger effect was observed for traffic fatality (-7.2 and -16.0% in the average monthly rate in the State and capital, respectively) compared to traffic injury rates (-1.8 and -2.3% in the State and capital, respectively).

CONCLUSIONS

Lowering the blood alcohol concentration limit in Brazil had a greater impact on traffic fatalities than injuries, with a higher effect in the capital, where presumably the police enforcement was enhanced.