Road traffic injury prevention training manual
Item
- Title
-
Road traffic
injury prevention
training manual - extracted text
-
http://www.who.int/violence_injury_prevention/capacitybuilding/teach_vip/en/index.htm
Injury
Surveillance
Guidelines
Guidelines for
conducting community
surveys on Injuries and violence
Community Health Cell
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http://www.who.int/violencejnjury_prevention/en/
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Selected WHO publications
1 1ft
09931
Road traffic
injury prevention
training manual
Dinesh Mohan, Geetam Tiwari,
Meleckidzedeck Khayesi and
Fredrick Muyia Nafukho
Wforld Health
Organization
INDIAN INSTITUTE OF
TECHNOLOGY DELHI
World Health Organization.
Road traffic injury prevention : training manual.
I .Accidents, Traffic - prevention and control 2.Data collection - methods 3.Emergency medical services - organization
and administration 4.Teaching materials 5.Manuals l.Title.
ISBN 92 4 154675 I
(NLM Classification: WA 275)
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WHO Library Cataloguing-in-Publication Data
Contents
Foreword......................................................................................................................................... v
Acknowledgements......................................................................................................................vii
Guidance to users .......................................................................................................................... 1
Unit I.
Magnitude and impact of road traffic injuries ........................................................................... 9
Unit 2.
Risk factors for road traffic injuries .......................................................................................... 21
Unit 3.
Importance of evidence as a foundation for prevention.......................................................... 41
Unit 4.
Implementing specific interventions to prevent road traffic injuries .................................... 61
Unit 5.
Delivering post-crash care........................................................................................................... 77
Unit 6.
Multisectoral collaboration ......................................................................................................... 89
Unit 7.
Formulating and implementing road safety policy................................................................ 101
Appendix.
Trainer’s evaluation of the manual .......................................................................................... Ill
Foreword
Road traffic injuries are the leading cause of death by injury, the eleventh leading cause of all deaths and the
ninth leading contributor to the burden of disease worldwide. Each year 1.2 million men, women and
children around the world lose their lives as a result of road traffic collisions. Hundreds of thousands more
are injured on the world's roads, some of whom become permanently disabled.
Human capacity to respond to this major public health concern is an important component of efforts to
prevent road traffic injuries. Policy-makers, researchers and practitioners need information on effective
prevention measures and how to develop, implement and evaluate such interventions. There is a need to
train more specialists in road traffic injury prevention in order to address the growing problem of road traffic
injuries at international and national levels. The World report on road traffic injury prevention, launched in
2004. identified the development of capacity as a key recommendation. Consequently, the World Health
Organization, in collaboration with the Transport Research and Injury Prevention Programme of the Indian
Institute of Technology in New Delhi, was prompted to develop this manual to provide guidance to
professionals working on road traffic injury prevention.
This manual equips the user with necessary information on: the magnitude and impact of the problem
of road traffic injuries; key risk factors; the need for a scientific approach to preventing road traffic injuries
and how to strengthen the evidence base for prevention; how to implement promising interventions; how
to deliver post-crash care; the need for multisectoral collaboration; and how to formulate and implement
road safety policies.
We hope that this manual, which is designed for a multidisciplinary audience including medical doctors,
nurses, transport and road engineers, vehicle safety professionals, law enforcers, policy-makers, urban
planners, and social scientists, will contribute towards strengthening capacity to implement measures to
prevent road traffic injuries in different settings around the world. The students of today will be the road
safety specialists of tomorrow.
Dr Etienne Krug
Director
Department of Injuries and Violence Prevention
World Health Organization
Contributors and acknowledgements
The World Health Organization acknowledges with thanks all those who contributed to this document, for
their support and expertise over the last four years. Particular thanks are due to a few dedicated individuals
who brought this document to fruition.
The writers - Dinesh Mohan and Geetam Tiwari, from the Transportation Research and Injury Prevention
Programme (TRIPP), Indian Institute of Technology Delhi, a WHO Collaborating Centre in Delhi, who
shared their experiences of running international road safety courses and used this to draft the manual. Also
to Fredrick Muyia Nafukho, University of Arkansas, USA, for his educational expertise during the writing
phase.
The advisory group - Dinesh Mohan and Geetam Tiwari (TRIPP), Margie Peden and Meleckidzedeck
Khayesi (WHO), Ian Roberts (UK), Anthony Bliss (World Bank). Frederick Muyia Nafukho (USA).
The Injury Prevention Initiative for Africa (IPIFA) who pilot tested the first draft of this document and gave
valuable feedback which was incorporated into the second draft which went out for external review.
The reviewers - Martha Hijar (Mexico), Tsegazeab Kebede (Ethiopia), Adnan Hyder (Pakistan/USA),
Wilson Odero (Kenya), Fred Wegman (The Netherlands), Andrew Downing (GRSP), Mark Stevenson
(Australia). Maarten Amelink (The Netherlands), David Meddings (WHO).
The final draft was edited by Angela Haden with support from Caroline Allsopp.
The production team - Pascale Lanvers-Casasola (administrative support), Biplab Kundu (design and
layout), Tami Toroyan (proofreading) and Marijke Bollaert (reference assistant).
Funding for this publication was kindly provided by the FIA Foundation for the Automobile and Society.
and the Swedish International Development Agency (S1DA).
GUIDANCE TO USERS » 3
Why was this manual developed?
Who are the intended users?
| rjew people are trained in road traffic injury
L_—I prevention. While there are growing efforts in
This manual is designed for a broad inter-disciplinary
audience consisting of people involved in preventing
road traffic injuries. This group includes medical
doctors, nurses, transport and road engineers, vehicle
safety professionals, law enforcers, policy-makers,
urban and regional planners, administrators, private
sector representatives, campaigners for road safety
and researchers. Since effective implementation of
road safety policies requires an interdisciplinary
approach, this manual provides guidance to workers
in a wide range of disciplines, who are involved in
different aspects of road traffic injury prevention in
different settings. Thus, this manual is aimed not only
at medical professionals, but also at professionals
from the public health and other sectors, who are
involved in preventing road traffic injuries.
different parts of the world to prevent road traffic
injuries, capacity remains a problem. The situation
is especially serious in low-income and middle
income countries. There is also an urgent need to
train practitioners and policy-makers in the
scientific approach to road traffic injury prevention.
There needs to be a cadre of professionals working
from a shared understanding of the magnitude of the
problem of road traffic injuries, risk factors and the
value of implementing evidence-based strategies.
This underscores the need for people working in the
area of road traffic injury prevention to be equipped
with appropriate knowledge and skills derived from
empirical evidence and professional wisdom.
Intervention programmes seeking to prevent road
traffic injuries need to address the problem of
capacity in different sectors (1).
This manual attempts to address the problem
of capacity for road traffic injury prevention by
providing guidance to professionals working on
road safety. The manual is part of a series of
training and evidence resources that have been
developed by the World Health Organization
(WHO) to help prevent violence and injuries. A
list of complementary documents is provided on
the inside back cover of this manual.
Structure and content
This manual is composed of seven complementary
units. Each unit is independent and can be taught or
learned separately. This structure gives facilitators
and trainers flexibility to customize the content for
different audiences.
The units provide users with information
enabling them to respond to key road safety
questions:
o What are the appropriate methods and
approaches for preventing road traffic injuries?
How was this manual developed?
o What policies and strategies have been shown to
be successful?
This manual was developed jointly by WHO and
the Transport Research and Injury Prevention
Programme of the Indian Institute of Technology in
New Delhi, India. It is based on the International
Training Course on Transportation Planning and
Safety offered by the Transport Research and
Injury Prevention Programme (2), the World report
on road traffic injury prevention (I), the TEACHVIP curriculum (3) and other relevant documents
produced by WHO (see outside and inside back
covers). All the relevant information was gathered
and a draft of the manual was prepared, pilot tested.
peer reviewed, and revised, ultimately being
published in the present form. It is envisaged that
the manual will be further refined in the light of
experience in its use.
o What strategies should be implemented for
maximum benefits?
o What can road safety professionals do to initiate
and sustain viable programmes to improve road
safety?
This manual equips users with specific
information on:
o magnitude and impact of road traffic injuries:
o risk factors for road traffic injuries;
o importance of evidence as a foundation for
prevention;
o implementing specific interventions to prevent
road traffic injuries;
o delivering post-crash care;
Suggestions for facilitators
o formulating and implementing road safety
policy.
Which units to offer?
Each unit is designed to promote interaction and
action. Each unit begins with an overview of the
unit's content and a list of learning objectives to
help in assessing whether or not the delivery of
content has achieved the expected outcomes. Each
unit provides examples to illustrate concepts and
questions relating to the prevention of road traffic
injuries. Learning activities are provided to give
the trainees practical exercises. Key points
summarize the information that the facilitator
should emphasize, and the main concepts are
defined.
Using this manual effectively
This manual provides principles and information to
meet training needs in different settings. It can be
used in facilitator-guided training, as well as for
self-learning. Users are expected to be creative and
innovative. Some suggestions for facilitators and
trainees on how they can effectively use this
manual are given here.
Professionals working on road safety have
different levels of prior knowledge. Some may
have had formal training, while others may not.
Also, these professionals are likely to be
working on different aspects of road safety.
Trainers are advised to consider the needs of
different audiences, especially their pre-existing
knowledge and practical needs in their work.
The modular structure of this manual allows for
flexibility in customizing the content to meet
different training needs. Box 1 suggests some
factors to consider when selecting units on
which a training session will be based.
Trainers are advised to carefully assess training
needs in each setting and choose the units
appropriately. It will require trainers to consult
relevant institutions and interact directly with the
training audience in advance of the training.
Adapting the content to a local context
This manual provides key principles and discusses
universal problems, but these principles and problems
Some factors to consider in selecting units
• What is the pre-existing knowledge level of the audience? In particular, how sound is their
grasp of the fundamentals of road traffic injury prevention?
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o multisectoral collaboration;
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4 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
• Are these trainees actively working in a capacity directly related to road traffic injury pre
vention? If so, do they need to acquire competencies for their work? If not, do they only need
to be made aware of some of the concerns in this area?
• For trainees engaged in road traffic injury prevention, how can the selection of lessons be
optimized so as to make the training session of direct relevance to their current activities?
• How much time is available for the planned training session? What is a realistic number of
units to provide, taking into account any participatory exercises, discussions and group work
that are also planned?
ff
• Is the knowledge level of the audience such that they can be expected to participate actively
in various forms of participatory learning? If so, how might the selection of units take advan
tage of this?
GUIDANCE TO USERS « 5
need to be made relevant to the local context. While
the importance of adapting the content to local
situations cannot be underestimated, trainers who are
overseeing the local adaptation of the training
materials must ensure that the fundamental principles
are not radically changed or misrepresented. It is also
important to ensure that the material, when adapted to
a specific local setting, remains accurate.
There are a number of ways of adapting this
manual to a local context. Trainers can do this by:
o modifying the style and level of content in view
of the pre-existing knowledge base of the
training audience;
o introducing local experiences into the training
materials to make the course meaningful to the
audience, for instance by considering the local
implications of road traffic collisions, risk
factors and policy development;
o substituting locally relevant examples for the
illustrative examples in the manual;
o adding new topics at the request of specific
audiences, and developing materials for these
topics;
o asking trainees to look for examples in advance
and make presentations on them during the
training sessions;
o inviting local decision-makers, government
officials, nongovernmental organizations, staff of
transport companies and insurance companies, and
victims and researchers to share their knowledge,
experience and projects.
While the manual covers the main topics in
road traffic injury prevention, it is possible that
other specific topics, such as enforcement and
programme implementation, need to be added in
certain local settings. Trainers should respond
adequately to requests by an audience to deal
with such matters, and are urged to share
information on additional topics with WHO to
assist in the future revision of this manual.
between the trainer and trainees, but also among all
those involved in a learning context. One way of
achieving this is through promoting active
participation and interaction during learning
sessions. There are a number of activities that can
be used to achieve this, examples of which are
given in Table 1. Judicious use of the suggested
activities will greatly improve the quality of
training sessions, making them extend beyond the
mere authoritarian transmission of content from
facilitators to trainees. Trainees will be able to
discover the knowledge by themselves and think
critically about how to apply it in the context of the
practical needs that arise in their work. In addition.
they will be able to construct knowledge from their
own perspectives, making what they are learning
meaningful.
Suggestions for trainees
Trainees are important players in this course. This
manual is meant to develop their capacity to
prevent road traffic injuries. Trainees are therefore
expected to:
o read the content before the training session and
prepare a set of questions on matters to be
clarified during the session;
o actively participate during training sessions by
voicing ideas and opinions, engaging in class
discussions, asking and answering questions,
sharing knowledge and experiences with
others, and doing exercises given by
facilitators;
o review learning activities, and where possible
gather local examples and data:
o take notes during the training sessions;
o read the references and the recommended
further reading;
o find practical ways of using the content of this
manual to initiate and support road safety
activities in the their local settings;
o read the content again after the training session.
Making training sessions participatory
and interactive
Learning is a two-way process and it is important to
enhance opportunities for learning, not only
Each unit includes a section listing questions to
think about. These questions are intended to guide
trainees in identifying some practical activities to
work on after the training.
6 » ROAD TRAFFIC INJURY PREVENTION- TRAINING MANUAL
TABLE 1
Suggested activities for participatory learning
Activity
Description
Partner collaboration
In pairs, each person explains a topic, concept or answer to his or her
partner. The partner listens and then asks questions or discusses.
Partner exercises
Peer evaluation
Divide the class into pairs. Partners exchange written work or listen to
each other's oral presentations. They give each other feedback and work
together to identify what was good, what needed improvement and how it
could be improved.
Case studies
A study or scenario is presented to the class or provided as a hand-out.
Groups discuss the study or scenario together in response to questions.
Fishbowl
One group discusses a topic. A second group observes the discussion
and each person records:
o
Group exercises
a partner's contribution (and gives individual feedback afterwards);
o the important parts of the discussion (for example, identifying problems,
applications or generalizations).
Group discussion
Groups (up to six people) talk about a topic. A set of questions from the
facilitator helps to structure the discussion and focus the group.
Syndicates
Groups of trainees work together on projects that entail researching and
presenting information. This approach is useful for building group and
cooperative skills while covering content.
Panel
One or more people with technical expertise are invited to the session to
answer questions from the class. These people may be government
representative, other trainers, medical personnel or trainees.
Classroom exercises
Presentations
Individuals or small groups find information on a topic, then prepare and
deliver a short informative session to the wider group.
Question-and-answer session
This is a useful activity to check trainees' understanding. Time is set aside
to discuss and answer questions.
GUIDANCE TO USERS ° 7
Evaluation
Trainers are advised to evaluate the units taught whenever they use this manual. Two kinds of evaluation
have been developed for this manual. The first is the trainee's evaluation of each unit. A form is provided at
the end of each unit to assist the facilitator get feedback from trainees on how well each individual unit was
delivered. The facilitator should make enough copies of the forms so that every trainee can fill one in. The
second is the facilitator's or trainer's evaluation of the manual. A trainer's evaluation form is included in the
Annex at the end of the manual for this purpose. WHO encourages facilitators and trainers to evaluate this
manual and to send their evaluations to WHO (as a hard copy or an electronic copy) at the following
address:
World Health Organization
Department of Injuries and Violence Prevention
20 Avenue Appia
CH-1211 Geneva 27
Switzerland
E-mail: traffic@who.int
References
1.
Peden M et al. World report on road traffic
injury prevention. Geneva, World Health
Organization, 2004.
2.
Tiwari G. Mohan D. Muhlrad N, eds. The
way forward: transportation planning and
road safely. New Delhi, Macmillan
2005.
3.
Ltd.,
TEACH-V1P
curriculum
(electronic
resource). Geneva, World Health Organi
zation. 2005.
Unit 1 . MAGNITUDE AND IMPACT OF ROAD TRAFFIC INJURIES ° 11
Overview
oad traffic injuries are a growing public
health and development problem. In this
unit, we examine in detail the magnitude and
impact of road traffic injuries using evidence at
global, regional and national levels. This
evidence shows how serious the problem of road
traffic injuries is at present and indicates that it
will become worse if no appropriate action is
taken now.
S
Objectives
FIGURE 1.1
Distribution of global injury mortality by cause
Suicide
16.9%
Other
unintentional injuries..
18.1%
Violence
10.8%
7.3%
Fires
6.2%
War
3.4%
Falls
7.5%
Poisoning
6.7%
By the end of this unit, the trainee should be able
to:
Other
intentional injuries
Road traffic
0.2%
22.8%
Source reproduced from reference 1
o describe the global magnitude and trends of
road traffic fatalities;
o discuss the global socioeconomic and health
burden of road traffic injuries:
o describe the magnitude and trends of road
traffic injuries in his or her own country.
region and city;
o discuss the socioeconomic and health burden
of road traffic injuries in his or her own
country, region and city.
Global estimates and pattern
Data provided by the World Health Organization
(WHO) and the World Bank were used for the
statistical analyses that form the basis of the World
report on road traffic injury prevention (1). In
summary, these data showed that, in 2002:
Note: Unintentional (or "accidental”) injuries are those
attributable to road traffic crashes, falls, drowning and
fires. Intentional (or deliberate) injuries are those
attributable to violence, suicide and war.
5098 million people or 81% of the world's
population live (2) and own about 20% of the
world's vehicles.
o The WHO African Region had the highest
mortality rate, with 28.3 deaths per 100 000
population. This was followed closely by the
low-income and middle-income countries of the
WHO Eastern Mediterranean Region, at 26.4
per 100 000 population (Table 1.1). Countries in
the WHO Western Pacific Region and the WHO
South-East Asia Region accounted for more
than half of all road traffic deaths in the world.
TABLE 1.1
o 1.2 million people died as a result of road traffic
collisions. This means that on average 3242
people were killed daily on the world's roads.
o 20 million to 50 million people were injured or
disabled in road collisions.
o Road traffic injuries were the 11"' leading
cause of death worldwide and accounted for
2.1% of all deaths globally. Furthermore,
these road traffic deaths accounted for 23%
of all injury deaths worldwide (Figure 1.1).
o 90% of road traffic deaths occurred in lowincome and middle-income countries, where
Road traffic injury mortality rates (per 100 000
population) in WHO regions, 2002
WHO region
Low-income
High-
and middle
income
income countries
countries
African Region
28.3
Region of the Americas
16.2
14.8
South-East Asia Region
18.6
—
European Region
17.4
11.0
Eastern Mediterranean Region
26.4
19.0
Western Pacific Region
185
12.0
Source: reproduced from reference 1.
12 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
o Road traffic injuries are predicted to rise from
tenth place in 2002 to eighth place by 2030 as a
contributor to the global burden of diseases
(Figure 1.3).
Globa! trends and projections
The key findings on global trends and projections
presented in the World report on road traffic injury
prevention (1} are summarized below:
o The number of road traffic injuries has continued
to rise in the world as a whole, but there has been
an overall downward trend in road traffic deaths
in high-income countries since the 1970s, and an
increase in many of the low-income and middle
income countries (Figure 1.2).
o Road traffic deaths are predicted to increase by
83% in low-income and middle-income
countries (if no major action is taken), and to
decrease by 27% in high-income countries. The
overall global increase is predicted to be 67%
by 2020 if appropriate action is not taken
(Table 1.2).
FIGURE 1.2
Global and regional road fatality trends, 1987-1995°
a Data are displayed according to the regional classifications of TRL Ltd. United Kingdom.
Source- reproduced from reference 3.
FIGURE 1.3
Change in rank order for the 10 leading causes of death, world, 2002-2030
2002
Rank
2030
Disease or injury
Rank
Disease or injury
1.
Ischaemic heart disease
1.
Ischaemic heart disease
2.
Cerebrovascular disease
2.
Cerebrovascular disease
3.
Lower respiratory infections
3.
HIV/AIDS
4.
HIV/AIDS
4.
Chronic obstructive pulmonary disease
5.
Chronic obstructive pulmonary disease
5.
Lower respiratory infections
6.
Perinatal conditions
6.
Diabetes mellitus
7.
Diarrhoeal diseases
7.
Trachea, bronchus, lung cancers
8.
Tuberculosis
9.
Trachea, bronchus, lung cancers
10.
Road traffic injuries-----------
Source: reference 4.
_^8.
______ _
Road traffic injuries
9.
Tuberculosis
10.
Perinatal conditions
Unit 1. MAGNITUDE AND IMPACT OF ROAD TRAFFIC INJURIES » 13
TABLE 1.2
Predicted road traffic fatalities by region (in thousands), adjusted for underreporting, 1990-2020
World Bank
Region3
Number of
countries
surveyed
1990
2000
2020
2010
Change (%)
2000-2020
Fatality rate
(deaths per
100 000 persons)
2000
2020
East Asia and Pacific
15
112
188
278
337
79
109
16.8
East Europe and
Central Asia
9
30
32
36
38
19
19.0
21.2
Latin America
and Caribbean
31
90
122
154
180
48
26.1
31.0
Middle East and
North Africa
13
41
56
73
94
68
192
22.3
South Asia
7
87
135
212
330
144
10.2
18.9
Sub-Saharan Africa
46
59
80
109
144
80
123
14.9
Sub-total
121
419
613
862
1 124
83
13.3
19.0
118
78
13.0
17.4
High-income countries
35
123
110
95
80
-27
Total
156
542
723
957
1 204
67
a Data are displayed according to the regional classifications of the World Bank.
Source- reference 5.
Wh© is eaffected by rocsd
traffic injuries?
The World report on road traffic injury
prevention (1) indicates that there are
notable differences in the way different
road users are affected by road traffic
collisions as summarized below:
FIGURE 1.4
Road users killed in various modes of transport as a
proportion of all road traffic deaths
Australia
Delhi. India
Bandung, Indonesia
o More than half of all global road traffic
deaths occur among young adults
between 15 and 44 years of age.
o 73% of all global road traffic
fatalities are males.
o Vulnerable road users - pedestrians,
cyclists and motorcyclists - account
for a much greater proportion of road
traffic collisions in low-income and
middle-income countries than in highincome countries (Figure 1.4).
Japan
Malaysia
Netherlands
Norway
Colombo. Sri Lanka
Thailand
USA
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
■ Pedestrians ■Bicyclists a Motorized two-wheeiers
Source, reproduced from reference 6
Motorized four-wheelers ■ Omer
4 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
to lose (3). It is important to estimate the cost of
road traffic injuries to society:
Activity
o to justify the expenditure necessary in promo
ting road traffic injury prevention;
Task
Look at Table 1.3 which presents data on
estimated road traffic fatalities per 100 000
population in the WHO African Region for 2002.
Carefully study the table and write down key
features related to the distribution of road traffic
fatalities per 100 000 by sex and age.
o to make the best use of investments when
different options are available;
o to ensure that the most cost-effective safety
improvements are introduced in terms of the
benefits that they will generate in relation to the
cost of their implementation.
Expected results
The purpose of this exercise is to assist
trainees to identify and summarize key
elements in the distribution of road traffic
fatalities per 100 000 population for the WHO
African Region. They are to describe
variations noted in this indicator by different
age groups for males and females.
TABLE 1.3
Estimated mortality0 caused by road traffic
injury'3 in WHO African region
Agec in years
Males
Females
0-4
18.6
11.0
5-14
42 6
25 5
15-29
27.2
10.0
30-44
53.4
15 0
45-59
65.7
22.1
60 and above
81.9
35.8
Total
39 3
174
a Mortality is measured by number ol road tralfic fatalities per
Global estimates of cosfs of road
traffic crashes
It is estimated that road traffic crashes cost (Table 1.4):
o USS 518 billion globally;
o USS 65 billion in low-income and middle-income
countries, exceeding the total amount received in
development assistance;
o between 1 % and 1.5 % of gross national product
in low-income and middle-income countries;
and
o 2% of gross national product in high-income
countries.
Road traffic injuries put significant strain on
families (I). For everyone killed, injured or
TABLE 1.4
Road crash costs by region
Region3
GNP, 1997
(USS
billion)
100 000 population.
b Road traffic injury = ICD10 V01-V89. V99, Y850 (ICD9
Estimated annual crash costs
As percentage of
Costs
GNP
(USS billion)
Africa
370
1
37
c Age-standardized
Asia
2 454
1
24.5
Source: reproduced from reference I.
Latin America
and Caribbean
1 890
1
18.9
Middle East
495
1.5
7.4
Central and
eastern Europe
659
1.5
9.9
E810-E819, E826-E829. E929).
Socioeconomic and healih
effecfs of road traffic injuries
Road traffic injuries cause emotional, physical
and economic harm. There is a moral imperative
to minimize such losses. A case can also be
made for reducing road crash deaths on
economic grounds, as they consume massive
financial resources that countries can ill afford
Subtotal
5 615
Highly motorized
countries
22 665
Total
64.5
2
453.3
517.8
GNP: gross national product.
a Data are displayed according to regional classification of the
TRL Ltd, United Kingdom
Source: reproduced from reference 3.
Unit 1 . MAGNITUDE AND IMPACT OF ROAD TRAFFIC INJURIES - 15
BOX 1.1
Cost of road traffic injuries to households
A case study conducted in Bangladesh found that poor families were more likely than those
better off to lose their head of household and thus suffer immediate economic effects as a result
of road traffic injuries. The loss of earnings, together with medical bills, funeral costs and legal
bills, can have a ruinous effect on a family's finances. Among poor people, 32% of the road
deaths surveyed in the Bangladesh study occurred to a head of household or that head's spouse,
compared to 21 % among those not defined as poor. Over 70% of households reported that their
household income, food consumption and food production had decreased after a road death.
Three-quarters of all poor households affected by a road death reported a decrease in their living
standard, compared to 58% of other households. In addition. 61% of poor families had to
borrow money as a result of a death, compared with 34% of other families.
Source: based on reference 1
disabled by a road traffic crash there are many
others deeply affected. Many families are driven
into poverty by the cost of prolonged medical
care, the loss of a family breadwinner, or the
extra funds needed to care for people with
disabilities. Road crash survivors, their families,
friends and other caregivers often suffer adverse
social, physical and psychological effects.
Various studies have made an effort to analyse
some of these detailed aspects (Box 1.1) but
further research is needed in this area. There is a
need not only for more evidence but also for
improvement in methods of data collection and
analysis, especially concerning poor families
and communities.
overall downward trend in road traffic deaths in
high-income countries and an increase in many
of the low-income and middle-income countries.
o Globally, the economic cost of road traffic
injuries is about USS 518 billion with lowincome and middle-income countries accoun
ting for USS 65 billion.
o Road traffic injuries put significant financial
strain on families. Many families are driven
into poverty by the cost of prolonged medical
care, the loss of a family breadwinner or the
extra funds needed to care for people with
disabilities.
Key poinfs
o Road crash survivors, their families, friends and
other caregivers often suffer adverse social,
physical and psychological effects.
o Worldwide, about 1.2 million persons are killed
in road traffic crashes every year.
Definitions of key concepts
o 20 million to 50 million more are injured or
disabled in these crashes.
o Road traffic fatality: a death occurring within 30
days of the road traffic crash.
o Road traffic injuries account for 2.1% of global
mortality and 23% of all injury deaths
worldwide.
o DALY (Disability-adjusted life year): a health
gap measure that combines information on the
number of years lost from premature death with
the loss of health from disability.
o The position of road traffic injuries as a
contributor to the global burden of disease is
predicted to rise from tenth place in 2002 to
eighth place by 2030.
o Over the past four decades there has been an
o Willingness to pay approach: an approach used
by economists to measure the value of pain and
suffering by asking people what they are willing
to pay or by studying what people actually pay
16 o ROAD TRAFFIC INJURY PREVENTION; TRAINING MANUAL
family and immediate society. Think of ways of
using this information to enhance prevention of
road traffic injuries in your local setting.
for small improvements in their chance of
avoiding the risk of being killed or injured.
o Prevalence costs: costs that measure all injuryrelated expenses during one year, regardless of
when the injury occurred.
o Incidence-based costs: costs that take into
account the lifetime costs that are expected to
result from injuries that occur during a single
year.
References
1.
Peden M et al. World report on road traffic
injury prevention. Geneva, World Health
Organization, 2004.
2.
World population prospects: the 2002
revision. Volume I: Comprehensive tables.
New York, United Nations, 2003.
3.
Jacobs G, Aeron-Thomas A, Astrop A.
Estimating global road fatalities. Crowthorne, Transport Research Laboratory, 2000
(TRL Report 445).
4.
Mathers C, Loncar D. Updated projections of
global mortality and burden of disease, 20022030: data sources, methods and results.
Geneva, World Health Organization, 2005.
5.
Kopits E, Cropper M. Traffic fatalities and
economic growth. Washington, DC, World
Bank, 2003 (Policy Research Working Paper
No. 3035).
6.
Mohan D: Traffic safety and health in Indian
cities. Journal of Transport and Infrastruc
ture, 2002, 9:79-94.
Questions to think about
.
What challenges does your country face as a
result of road traffic crashes?
In most countries, road traffic injury costs
exceed I % of gross national product. This figure
is generally considered to be an underestimate
of national road crash costs. What is the
estimated cost of road traffic injuries in your
country? How is this estimate derived? How
frequently is this estimate updated?
.. Conduct a review of literature to establish how
much research has been done on costs of road
traffic injuries in your country. Look for
published research on this issue in both local
and international journals. This activity is meant
to equip you with library research skills and the
capacity to examine existing literature. You can
work on your own, or with two or three
colleagues. Try to summarize the results and
indicate gaps in knowledge that need to be
filled. Consider preparing a manuscript based
on your review to submit to a journal.
; Identify a family you know where someone has
been involved in a non-fatal road crash recently.
Seek permission to gather information on the
economic costs of that crash for that family.
Prepare a summary of the economic costs to the
Further reading
Hauer E. Can one estimate the value of life or is it
better to be dead than stuck in traffic?
Transportation Research Series A, 1994,
28:109-118.
Trinca G et al. Reducing traffic injury: the global
challenge. Melbourne. Royal Austra-lasian College
of Surgeons, 1988.
Unit 1 . MAGNITUDE AND IMPACT OF ROAD TRAFFIC INJURIES • 17
Notes
18 » ROAD TRAFFIC INJURY PREVENTION TRAINING MANUAL
Trainee's evaluation of Unit 1: Magnitude and impact of road traffic injuries
This form is to be completed by the trainee at the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
I.
To what extent did you achieve the objectives set for this unit? (Please check once using “X" for each
objective)
Completely
successful
Objectives
Generally
successful
Completely
unsuccessful
Describe the global magnitude and
trends of road traffic fatalities.
Discuss the global socioeconomic and
health burden of road traffic injuries.
Describe the magnitude and trends of
road traffic injuries in your own
country, region and city.
Discuss the socioeconomic and health
burden of road traffic injuries in your
own country, region and city.
2.
What is your overall rating of the content presented in this unit? (Please check one using "X”)
Scale
Excellent
Better than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
b)
If yes, in what ways were they helpful? What improvements do you suggest?
c)
If no, what were the shortcomings? What suggestions do you have to make them helpful?
Unit 1. MAGNITUDE AND IMPACT OF ROAD TRAFFIC INJURIES ° 19
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you learn most from this unit?
8.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES • 23
Public health approach
Overview
I road
traffic
crash
results
front
a
Sm combination of factors related to the
components of the system comprising roads, the
environment, vehicles and road users, and the
way they interact. Some factors contribute to the
occurrence of a collision and are therefore part of
crash causation. Other factors aggravate the
effects of the collision and thus contribute to
trauma severity. Some factors may not appear to
be directly related to road traffic injuries. Some
causes are immediate, but they may be
underpinned by medium-term and long-term
structural causes. Identifying the risk factors that
contribute to road traffic crashes is important in
identifying interventions that can reduce the
risks associated with those factors.
This unit is devoted to discussing risk
factors for road traffic injuries. The first part of
the unit provides frameworks that can be used to
identify and analyse risk factors. The second part
discusses the key risk factors.
Objectives
By the end of this unit, the trainee should be able
to:
o discuss the basic elements of the public health
approach and Haddon matrix;
o apply the principles of a systems approach to
the analysis of risk factors for road traffic
injuries;
o discuss the key risk factors for road traffic
injuries;
The public health approach is a generic analytical
framework that has made it possible for different
fields of public health to respond to a wide range of
health problems and diseases, including injuries
and violence (/, 2). This approach is not only
helpful in the analysis of risk factors, but also
provides a framework that guides decision-making
throughout the entire process, from identifying a
problem to implementing an intervention. Analysis
of risk factors is one of the components of this
approach, and that is why we have included it here
for application to road traffic injuries.
The public health approach involves four
interrelated steps (Figure 2.1):
o The first step is to determine the magnitude,
scope and characteristics of the problem.
Defining the problem goes beyond simply
counting cases: it includes delineating mortality,
morbidity, and risk-taking behaviour. In the case
of road traffic injuries, this step includes
obtaining information on the demographic
characteristics of the people involved, the
temporal and geographical features of the
incident, the circumstances under which it
occurred, and the severity and cost of the
injuries. Quantitative (for example, surveys) and
qualitative (for example, focus group
FIGURE 2.1
The public health approach
D
o relate these risk factors to the trainee’s own
country, region and city.
Risk factor
Surveillance
What is the
identification
What are the
problem?
causes:
Analytical frameworks
Various analytical frameworks can be used to
identify the risk factors involved in road traffic
injuries. In this section, we present three
frameworks or approaches: the public health
approach; the Haddon matrix; and the systems
approach.
4)
Implementation
How is it done?
3)
Develop and
evaluate
interventions
What works?
24 ■> ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
discussions) research methods drawn from the
behavioural and social sciences are increasingly
being used to identify and characterize
problems.
o The second step is to identify the factors that
increase the risk of disease, injury or disability.
and to determine which factors are potentially
modifiable. Whereas the first step looks at “who,
when, where, what and how”, the second step
looks at “why”. It may also be used to define
populations at high risk for injuries and violence
and to suggest specific interventions.
o The third step is to assess what measures can be
taken to prevent the problem by using the
information about causes and risk factors to
design, pilot test and evaluate interventions.
This step aims at developing interventions based
upon information obtained from the previous
steps and testing these or other extant
interventions. Methods for testing include
randomized controlled trials, controlled
comparisons of populations for occurrence of
health outcomes, cohort studies, time series
analyses of trends in multiple areas, and
observational studies such as case control
studies. An important component of the
evaluation step is to document the processes that
contribute to the success or failure of an
intervention, in addition to examining the
impact of interventions on health outcomes.
o The final step is the implementation of
interventions that have been proven or are highly
likely to be effective on a broad scale. In both
instances it is important that data are collected to
evaluate the programme’s effectiveness in
actually reducing road traffic injuries and
fatalities, particularly since an intervention that
has been found effective in a clinical trial or a
small study may perform differently at the
community level, or when expanded to target
broader populations or geographical areas.
Another important component is determining the
cost-effectiveness of such
programmes.
Balancing the costs of a programme against the
cases prevented by the intervention can be helpful
to policy-makers in determining optimal public
health practice. Implementation also implies
health communication, the formation of
partnerships and alliances as well as developing
methods for community-based programmes.
Though each of the four steps is presented
separately, it is important to remember that in
reality these steps may overlap in terms of the
timing in which they are implemented.
Haddon matrix
William Haddon (3) developed a matrix that
identifies risk factors before the crash, during the
crash and after the crash, in relation to the person,
vehicle and environment (Table 2.1). Haddon
TABLE 2.1
The Haddon matrix
Pre-crash
Crash
Information
Roadworthiness
Road design and road layout
prevention
Attitudes
Impairment
Lighting
Speed limits
Pedestrian facilities
Police enforcement
Braking
Handling
Speed management
Crash
Injury prevention
during the crash
Use of restraints
Life sustaining
First-aid skill
Ease of access
Access to medics
Fire risk
Impairment
Occupant restraints
Other safety devices
Crash-protective roadside objects
Crash protective design
Post-crash
Source: reference 3.
Rescue facilities
Congestion
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES • 25
described road transport as an ill-designed “man
machine” system in need of comprehensive
systemic treatment. Each phase - pre-crash, crash
and post-crash - can be analysed systematically for
human, vehicle, road and environmental factors.
The Haddon matrix is an analytical tool to help in
identifying all factors associated with a crash. Once
the multiple factors associated with a crash are
identified and analysed, countermeasures can be
developed and prioritized for implementation over
short-term and long-term periods. For the pre-crash
phase, it is necessary to select all countermeasures
that prevent the crash from occurring. The crash
phase is associated with countermeasures that
prevent injury from occurring or reduce its severity
if it does occur. Finally, the post-crash phase
involves all activities that reduce the adverse
outcome of the crash after it has occured.
Systems approach
Traditionally, analysis of risk has examined the road
user, vehicle and road environment separately.
Furthermore, there is a tendency by researchers and
practitioners to look for one or a few factors, when
in actual fact they should be analysing multiple
factors. Building on Haddon's insights, the systems
approach (where interactions between different
components are taken into account) seeks to
identify and rectify the major sources of error, or
design weaknesses, that contribute to fatal crashes
or crashes that result in severe injury, as well as to
mitigate the severity and consequences of injury.
The essence of using a systems approach is to
consider not only the underlying factors, but also
the role of different agencies and actors in
prevention efforts. Road traffic injuries are a multi
dimensional problem that require a comprehensive
view when examining the determinants,
consequences and solutions.
Any road traffic system is highly complex and
can be hazardous to human health. Elements of the
system include motor vehicles, roads, and road
users along with their physical, social and
economic environments. Making a road traffic
system less hazardous requires a systems approach
— understanding the system as a whole and the
interaction between its elements, and identifying
where there is potential for intervention. In
particular, it requires recognition that the human
body is highly vulnerable to injury, and that
humans make mistakes. A safe road traffic system
is one that accommodates and compensates for
human vulnerability and fallibility (4).
Each crash and its consequences can be
represented by its system of interlinked factors
(Figure 2.2). As the components of the road and
transport system interact, linkages appear between
crash and trauma factors. For example, some road
features or vehicle characteristics may have
influenced particular aspects of road users’
behaviour, and the effects of some vehicle defects
may have been compounded by particular road
characteristics. For the purpose of planning
measures to avoid collisions, it is essential to
Activity
Task
Read carefully this description of a road traffic
collision scene. A speeding motorist who is late
for a meeting approaches a road junction and
goes through a traffic light that has just turned
red. He hits a motorcyclist, for whom the lights
had just turned green. The motorcyclist, who is
not wearing a helmet, suffers severe head
injuries. The motorist suffers facial injuries. The
police find out that the motorist had not pul on
his seat-belt. Using the Haddon matrix shown in
Table 2.1, identify the pre-crash, crash and post
crash risk factors related to the driver and the
motorcyclist.
Expected results
This exercise is meant to assist trainees in
identifying the chain of events involved in road
traffic injury causation. The exercise seeks to
identify a few risk factors in this scene and
classify them under the three phases of the
Haddon matrix (pre-crash, crash, and post-crash)
and by group (human, vehicle and equipment,
and environment). In addition to identifying the
risk factors, this exercise should lead trainees to
look at the interaction among different elements
of the broader system of road, road user, vehicle
and environment, in the case presented.
26 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
FIGURE 2.2
The systems approach
Road and transport system
Work
School
------ t>
Leisure
Shopping
Others
System of trips
Vehicle
factors
Human
factors
Road and
environmental
factors
Crashes and crash factors
Source: reference 5.
understand the full complex causation process, as it
provides vital information, and usually leads to a
wide scope of possible areas of preventive action.
There is an opportunity for intervention in all
aspects of the transport system, and related systems
indicated in Figure 2.2, to reduce the risk of road
traffic injuries and deaths. The key message to take
from Figure 2.2 is that a road traffic crash or
collision is the outcome of interaction among a
number of factors and subsystems.
If road traffic crashes are reduced to one
“cause” only, it is obvious that the components
of the system - human, infrastructure and
vehicle factors - are necessarily considered as
independent. Measures addressing any one
component can thus be implemented separately,
which makes things easier as the decision
makers responsible for each area of intervention
do not have to coordinate with the others.
However, opportunities to influence one type of
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES
factor through another (for example, to obtain
more appropriate driver behaviour through
changes in road design) are entirely ignored.
Moving away from the simplified model for
road safety action to a systems approach
requires that considerable effort be put into
acquisition of knowledge of the nature of
crashes. This effort is rewarded by the larger
range of opportunities opened up for preventive
action and by the more appropriate design of
measures. Getting sufficient knowledge of the
factors generating hazards in the road and transport
system implies analysing the chain of events
leading to crashes and injuries. As crash factors
relate to human as well as to physical and technical
components of the road and transport system,
detailed analysis of road crashes may require a
multidisciplinary approach.
• Tl
What are the main risk factors?
Research has identified a number of risk factors for
road traffic injuries and these are discussed in the
recently published World report on road traffic
injury prevention (4). Box 2.1 provides a summary
of these factors.
Factors influencing exposure to risk
Movement of people and goods on the road is
necessary for social, economic and political
reasons, but this need to travel leads to a risk of
road traffic injuries. A range of factors determine
who uses different parts of the transport system,
how they use them and why, and at what times. It
may not be possible in practice to completely
eliminate all risk, but it is possible to reduce
BOX 2.1
The main risk factors for road traffic injuries
Factors influencing exposure to risk
— economic factors such as level of economic development and social deprivation;
— demographic factors such as age and sex;
— land-use planning practices which influence length of trip and mode of travel;
— mixture of high-speed motorized traffic with vulnerable road users;
— insufficient attention to integration of road function with decisions about speed limits, road
layout and design.
Risk factors influencing crash involvement
— inappropriate and excessive speed;
— presence of alcohol, medicinal or recreational drugs;
— fatigue;
— being a young male;
— having youths driving in the same car;
— being a vulnerable road user in urban and residential areas;
— travelling in darkness;
— vehicle factors - such as braking, handling and maintenance;
-— defects in road design, layout and maintenance, which can also lead to unsafe behaviour by
road users;
— inadequate visibility because of environmental factors (making it hard to detect vehicles and
other road users);
— poor eyesight of road users.
28 • ROAD TRAFFIC INJURY PREVENTION TRAINING MANUAL
BOX 2.1 (continued)
Risk factors influencing crash severity
— human tolerance factors;
— inappropriate or excessive speed;
— seat-belts and child restraints not used;
— crash-helmets not worn by users of two-wheeled vehicles;
— roadside objects not crash-protective;
— insufficient vehicle crash protection for occupants and for those hit by vehicles;
— presence of alcohol and other drugs.
Risk factors influencing post-crash outcome of injuries
— delay in detecting crash and in transport of those injured to a health facility;
— presence of fire resulting from collision:
— leakage of hazardous materials;
— presence of alcohol and other drugs;
— difficulty in rescuing and extracting people from vehicles:
— difficulty in evacuating people from buses and coaches involved in crash;
— lack of appropriate pre-hospital care;
— lack of appropriate care in hospital emergency rooms.
Source: reference 4.
exposure to the risk of severe injury and to
minimize its intensity and consequences. The
specific modes and issues of importance when
examining exposure to risk are fully discussed in
the World report on road traffic injury prevention
(4). A brief summary is given here.
Growth in number of motor vehicles
One of the main factors contributing to the increase
in global road crash injuries is the growing number
of motor vehicles. The problem is not just the
growth in numbers and increase in exposure to the
risk but also ensuring that appropriate road safety
measures accompany this growth. The motor
vehicle, along with the subsequent growth in the
number of motor vehicles and in road
infrastructure, has brought societal benefit but it
has also led to societal cost, to which road traffic
injury contributes significantly. Without proper
planning, growth in the number of motor vehicles
can lead to problems for pedestrians and cyclists. In
fact, where there are no facilities for pedestrians
and cyclists, increasing numbers of motor vehicles
generally lead to reductions in walking and cycling.
At present, motor vehicle growth in lowincome and middle-income countries is taking
place against a background of associated problems.
Only a small number of people in these countries
can afford cars, while the costs of roads, parking
spaces, air pollution and road traffic injuries are
borne by the whole society. Despite the rapid
growth in motorized traffic, most families in lowincome and middle- income countries are unlikely
to own a car within the next 25 years.
In terms of exposure to risk, the main modes of
travel in these countries in the foreseeable future
are likely to remain walking, cycling and public
transport. This emphasizes the importance of
planning for the needs of these road users, who. as
was seen in Unit I. bear a high proportion of the
burden of road traffic injuries. Buses and trucks are
a major mode of travel in low-income and middle
income countries. High volumes of passengers
being transported have an impact on the safely, not
only of the passengers themselves, but also of
vulnerable road users.
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES
Motorized two-wheeled and
three-wheeled vehicles
The substantial growth in the use of motorized twowheelers. particularly in low-income and middle
income countries, is being accompanied by an
increase in the number of head and traumatic brain
injuries. This is of particular concern in Asia where.
for many commuters, the motorized two-wheeler is
used as a family vehicle. Use of such vehicles
increases exposure to the risk of road traffic
injuries. Like other motor vehicles, motorized twowheelers and three-wheelers also cause injuries to
other road users as noted in their collisions with
buses, cars and pedestrians.
Non-moforized traffic
Non-motorized vehicles predominate in both rural
and urban areas in low-income and middle- income
countries. Overall in developing countries,
pedestrian and cyclist traffic has grown without
accompanying improvements in facilities for these
road users. The high number of pedestrian and
cyclist casualties in these countries reflects not only
the inherent vulnerability of these road users, but
also insufficient attention to their needs in policymaking.
Demographic factors
Different groups of people have different exposures
to risk. As populations change over time, so their
overall exposure will change. Fluctuations in the
relative sizes of different population groups will
have a strong effect on the road traffic toll. For
instance, in high-income countries, young drivers
and riders - at increased risk of involvement in
road crashes - are currently overrepresented in
casualty figures. Demographic changes in these
countries over the next 20-30 years, however, will
result in road users over 65 years of age becoming
the largest group of road users. The physical
vulnerability of older people places them at high
risk for fatal and serious injuries. Despite the rising
number of older people holding driving licences in
hieh-income countries, their declining driving
ability as well as possible financial constraints will
mean that many of them will have to give up
driving. This may differ from many low-income
' 29
countries where older people may never have
driven in the first place. In low-income countries in
general, the expected demographic evolution
suggests that younger road users will continue to be
the predominant group involved in road traffic
crashes. Worldwide, a large proportion of older
people will be dependent on public transport or will
walk. This illustrates the importance of providing
safe and short pedestrian routes, and safe and
convenient public transport.
Transport, land use and road network
planning
Planning decisions regarding transport, land use
and road networks have significant effects on
public health - as they affect the amount of air
pollution by vehicles, the degree of physical
exercise undertaken by individuals, and the volume
of road traffic crashes and injuries. The
development of a network of roads - or indeed of
other forms of transport, such as railways - has a
profound effect on communities and individuals. It
influences such things as economic activity,
property prices, air and noise pollution, social
deprivation and crime - in addition to health. Long
commuting times degrade the quality of life and
therefore health. Sedentary travel directly and
adversely affects health. In the absence of proper
land use planning, residential, commercial and
industrial activity will evolve in a haphazard
pattern, and road traffic will evolve similarly to
meet the needs of these various activities. This is
likely to produce heavy flows of traffic through
residential areas, vehicles capable of high speed
sharing space with pedestrians, and heavy, long
distance commercial traffic using routes not
designed for such vehicles. The consequent
exposure to road traffic injury may be high for car
occupants, and even more so for vulnerable road
users, such as pedestrians, cyclists and motorized
two-wheeler users.
Choice and use of less safe forms of travel
Of the four main modes of travel, road travel
presents the highest risk in most countries - using
almost any measure of exposure - compared with
rail, air and marine travel. Within this mode of road
30 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
travel, major variations exist between pedestrians.
cyclists, riders of motorized two-wheelers, car
occupants, and bus and truck passengers. The risks
for these road users also vary greatly according to
the traffic mix and hence vary greatly from country
to country. In general, in high-income countries,
riders of motorized two-wheelers have the highest
levels of risk.
increases as speed increases, especially at road
junctions and while overtaking - as road users
underestimate the speed and overestimate the
distance of an approaching vehicle.
Drivers’ speed choice is influenced by a
number of factors that can be considered as:
Factors influencing crash involvement
o factors relating to the road and the vehicle (road
layout, surface quality, vehicle power,
maximum speed);
This section provides a summary of selected factors
presented in the World report on road traffic injury
prevention (4).
Speed
The speed of motor vehicles is at the core of the
road traffic injury problem. Speed influences both
crash risk and crash consequence (Box 2.2). The
physical layout of the road and its surroundings can
both encourage and discourage speed. Crash risk
o driver-related factors (age, sex, alcohol level,
number of people in the vehicle);
o traffic-related and environment-related factors
(traffic density and composition, prevailing
speed, weather conditions).
Alcohol
Impairment by alcohol is an important factor
influencing both the risk of a road crash as well as
the severity of the injuries that result from crashes
Effecfis of speed on crashes and crash severity
o The higher the speed of a vehicle, the shorter the time a driver has to stop and avoid a crash.
A car travelling at 50 km/h will typically require 13 metres in which to stop, while a car
travelling at 40 km/h will stop in less than 8.5 metres.
o An average increase in speed of 1 km/h is associated with a 3% higher risk of a crash
involving an injury.
o In severe crashes, the increased risk is even greater. In such cases, an average increase in
speed of 1 km/h leads to a 5% higher risk of serious or fata] injury.
o Travelling at 5 km/h above a road speed limit of 65 km/h results in an increase in the relative
risk of being involved in a casualty crash that is comparable with having a blood alcohol
concentration of 0.05 g/dl.
• For car occupants in a crash with an impact speed of 80 km/h, the likelihood of death is 20
times what it would have been at an impact speed of 30 km/h.
o Pedestrians have a 90% chance of surviving car crashes al 30 km/h or below, but less than a
50% chance of surviving impacts at 45 km/h or above.
o The probability of a pedestrian being killed rises by a factor of 8 as the impact speed of the
car increases from 30 km/h to 50 km/h.
Source: reference 4.
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES ° 31
(Boxes 2.3 and 2.4). The frequency of drinking and
driving varies between countries but it is almost
universally a major risk factor for road traffic
crashes. The extent to which alcohol contributes to
road traffic crashes varies between countries, and
direct comparisons are difficult to make. In many
high-income countries, about 20% of fatally
injured drivers have excess alcohol in their blood
(i.e. above the legal limit). Studies in low-income
countries have shown alcohol to be present in
between 33% and 69% of fatally injured drivers.
Driver fatigue
Fatigue or sleepiness is associated with a range of
factors. Some of these factors with relevance to road
traffic are long-distance driving, sleep deprivation
and the disruption of circadian rhythms. Three highrisk groups have been identified:
— young people, particularly males, aged 16-29
years;
— shift workers whose sleep is disrupted by
working at night or working long, irregular hours;
Effects of alcohol on risk of crashes and of crash injury
o Drivers and motorcyclists with any blood alcohol content greater than zero are at higher risk
of a crash than those whose blood alcohol content is zero.
o For the general driving population, as the blood alcohol content increases from zero, the risk
of being involved in a crash starts to rise significantly at a blood alcohol content of 0.04 g/dl.
« Inexperienced young adults driving with a blood alcohol content of 0.05 g/dl have 2.5 times
the risk of a crash compared with more experienced drivers.
o If a blood alcohol content limit is fixed at 0.10 g/dl, this will result in three times the risk of
a crash than that at 0.05 g/dl, which is the most common limit in high-income countires. If
the legal limit stands at 0.08 g/dl, there will still be twice the risk than at 0.05 g/dl.
o Alcohol consumption by drivers puts pedestrians and riders of motorized two-wheelers at
risk.
Source: reference 4.
BOX 2.4
What factors affect alcohol-related road crashes?
o The risk of a road crash when a driver is alcohol-impaired varies with age. Teenagers are
significantly more likely to be involved in a fatal crash than older drivers. At almost every
blood alcohol level, the risk of crash fatality decreases with increasing driver age and
experience.
® Teenage drivers who are alcohol-impaired are at increased risk of having a road crash if they
have passengers in the vehicle, as compared with those driving alone.
o A low expectation of getting caught with a blood alcohol content above the legal limit has
been shown to lead to an increased risk of a crash.
Source: reference 4.
Factors that substantially increase the risk of a
fatal crash or a crash with serious injuries are:
— driving while feeling sleepy:
— driving after five hours of sleep;
— driving between 02:00 and 05:00.
In low-income and middle-income countries,
the phenomenon of pedestrians and vehicles not
being properly visible is frequently a serious
problem. In many places, there are fewer roads
with adequate illumination and some may not be lit
at all. In addition, it is more common for large
numbers of bicycles and other vehicles to have no
lights or reflectors and for road space to be shared
by fast-moving and slow-moving road users.
Commercial transport
Surveys of commercial and public road transport
have revealed that owners of public transport
vehicles, in pursuit of increased profits, frequently
force their drivers to drive at excessive speeds, to
work unduly long hours and to work when
exhausted.
Hand-held mobile telephones
The use of hand-held mobile telephones can
adversely affect driver behaviour - as regards
physical tasks as well as perception and decision
making. The process of dialling influences a
driver's ability to keep to the course on the road.
Results of studies on distraction and mental load
show that driver reaction limes are increased by
0.5-1.5 seconds when talking into a mobile
telephone. Studies have shown that driver
performance is particularly affected in maintaining
the correct lane position and the headway between
two vehicles travelling one behind the other, in
keeping to an appropriate speed, and in judging and
accepting safe gaps in the traffic. There is some
evidence from studies that drivers who use mobile
telephones while driving face a risk of a crash four
times higher than the risk for drivers who do not
use mobile telephones.
Inadequate visibility
In motorized countries, inadequate visibility plays
a key role in three types of crashes:
— a moving vehicle running into the rear or side of
a slowly moving or stationary vehicle located
ahead on the roadway, at night-time;
Road-related factors
Road crashes are not evenly distributed throughout
the network. They may occur in clusters at single
sites, along particular sections of road, or scattered
across whole residential
neighbourhoods,
especially in areas of social deprivation. While road
engineering can greatly help in reducing the
frequency and severity of road traffic crashes, it can
also contribute to crashes. The road network has an
effect on crash risk because it determines how road
users perceive their environment, and it provides
instructions for road users, through signs and traffic
controls, on what they should be doing. Many
traffic management and road safety engineering
measures work through their influence on human
behaviour.
Road engineering factors include those where a
road defect directly triggers a crash, where some
element of the road environment misleads a road
user and thereby creates error, or where some
feasible physical alteration to the road would have
made the crash less likely. In the planning, design
and maintenance of the road network, the following
four particular elements affecting road safety have
been identified:
o safety-awareness in the planning of new road
networks;
o the incorporation of safety features in the design
of new roads;
o safety improvements to existing roads;
□ remedial action at high-risk crash sites.
— angled collisions or head-on collisions in
daytime:
Factors influencing crash severity
— rear-end collisions in fog. in daytime and at
night.
Factors influencing crash severity are presented
in this section.
» fl 77 I! ff fl fl R fl fl fl fl fl fl B ff fl fl fl B B fl fl R fl fl fl
— people with untreated sleep apnoea syndrome or
narcolepsy.
1
7B
32 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES « 33
Lack of in-vehicle crash protection
In the past decade, the crashworthiness of private
cars for their occupants has improved
considerably in many high-income countries,
though there is still considerable room for further
improvement. In low-income and middle-income
countries, regulation of motor vehicle safety
standards is not as systematic as in high-income
countries. Many engineering advances to be
found in vehicles available in high-income
countries are not standard fittings in vehicles in
low-income and middle-income countries. In
addition, the majority of road casualties in lowincome and middle-income countries occur
outside the car, affecting pedestrians, cyclists,
motorized two-wheeled vehicle riders, or
passengers in buses and trucks. As yet, there are
no requirements to protect vulnerable road users
by means of crashworthy designs of the fronts of
trucks or buses.
The main injury risks for car occupants arise
from the way vehicles interact with each other and
with the roadside in frontal and side-impact
crashes. In fatal and serious crashes, head, chest
and abdominal injuries are predominant. Among
injuries that cause disability, those to the legs and
neck are important. Determinants of the degree of
severity of injuries include:
— contact by occupant with the car’s interior,
exacerbated by intrusion into the passenger
compartment of the colliding vehicle or object;
— mismatch in terms of size and weight between
vehicles involved in a crash;
— ejection from the vehicle;
countries. Such vehicles have low crashworthiness.
They also have poor stability when fully laden or
over-loaded, as they frequently are.
The urban centres of low-income and middle
income countries typically contain a great mix of
vehicles. Incompatibility of size between different
types of road vehicles is a major risk factor,
especially in impacts between cars and large trucks.
The power of the larger vehicle - its mass,
geometry and structural properties - increases rates
of injury and death many times compared with an
equivalent car-to-car collision.
Non-use of crash helmets by two-wheeled
vehicle users
The main risk factor for motorized two-wheeler
users is the non-use of crash helmets (Box 2.5). The
lack or inappropriate use of helmets has been shown
to increase the risk of fatalities and injuries resulting
from road crashes involving motorized twowheelers. Head injuries are a major cause of death,
injury and disability among users of motorized twowheel vehicles. Many of these head injuries could
have been prevented or their severity reduced
through the use of simple and inexpensive helmets.
Non-use of seat-belts and child restraints in
motor vehicles
The lack or inappropriate use of seat-belts and
other safety restraints (child seats and booster
seats) are risk factors for the fatalities and injuries
that result from road crashes (Box 2.6). The most
frequent and most serious injuries occurring in
frontal impacts to occupants unrestrained by seat
belts are to the head (Box 2.6).
— inadequate vehicle safety standards.
Roadside objects
Bus and truck occupants
Buses with passengers, minibuses and trucks are
frequently involved in crashes in low-income
countries. The use of open-backed vehicles for
transporting passengers, particularly widespread in
rural areas, presents a risk of ejecting passengers.
In many low-income and middle-income countries,
second-hand trucks and buses are imported without
the crash-protective features - .such as occupant
restraints - that are present in high-income
Impacts between vehicles leaving the road and
solid roadside objects such as trees, poles and road
signs are a major road safety problem worldwide.
These collisions are usually single-vehicle crashes
and frequently involve young drivers, excess or
inappropriate speed, the use of alcohol or driver
fatigue. Another problem related to impacts with
objects off the road is the occurrence of crashes
caused by restricted visibility, resulting from the
poor siting of these objects.
34 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Helmet wearing
o Non-helmeted users of motorized two-wheelers are three times more likely to sustain head
injuries in a crash compared to those wearing helmets.
o Helmet-wearing rates vary from slightly over zero in some low-income countries to almost
100% in places where laws on helmet use are effectively enforced.
o Although helmets have generally been widely worn in most high-income countries, there is
evidence of a decline in usage in some countries.
o More than half of adult riders of motorized two-wheelers in some low-income countries do
not wear their helmets properly secured.
o Child passengers rarely wear helmets, or wear adult helmets that do not adequately protect them.
o Helmet use does not have adverse effects on neck injuries, visibility or the ability to drive
safely in traffic.
Source reference 4.
BOX 2.6
Safety restraints
Seat-belt wearing
o Rates of seat-belt use vary greatly among different countries, depending upon the existence
of laws mandating their fitting and use and the degree to which those laws are enforced. In
low-income and middle-income countries, usage rates are generally much lower.
o Seat-belt usage is substantially lower in fatal crashes than in normal traffic.
o Young male drivers use their seat-belts less often than other groups and are also more likely
to be involved in crashes.
o The effectiveness of seat-belts depends upon the type and severity of the crash and the
seating position of the passenger.
<s Seat-belts are most effective in roll-over crashes and frontal collisions, and in lower speed crashes.
o Correctly used seat-belts reduce the risk of death in a crash by approximately 60%.
Child restraint use
• The use of child restraints (child seats and booster seats) in motor vehicles varies
considerably between countries and is mainly confined to high-income countries.
• The use of child restraints can reduce infant death in car crashes by 71 % and toddler deaths
by 54%.
o Child restraints work in the same way as adult seat-belts.
o The use of appropriate restraint depends on the age and weight of the child: rear-facing seats
are particularly effective for young infants, forward-facing restraints are appropriate for
younger children, and booster seats used with seat-belts are effective for older children.
• The potential hazard of combining air bags with rear-facing seats in the front seat of a vehicle
is well documented.
o There is a substantial amount of incorrect use of both adult seat-belts and child restraints.
which markedly reduces their injury-reducing potential.
Source: reference 4.
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES • 35
The linkage between vehicle crash protection
and roadside crash protection needs to be
strengthened. The road environment needs to be
designed so as to eliminate head-on collisions - into
trees, poles and other rigid objects - at high speeds,
where the car itself cannot offer sufficient protection.
Factors influencing post-crash injury
outcomes
Death is potentially preventable in a proportion of
cases of people who die as a result of road crashes
before they reach hospital. The potential help
towards recovery that victims can receive may be
viewed as a chain with several links:
o actions, or self-help, at the scene of the crash, by
the victims themselves, or more frequently by
bystanders;
□ access to the emergency medical system;
o help provided by rescuers of the emergency
services;
o delivery of medical care before arrival at the
hospital;
n factors influencing crash involvement, such
as inappropriate and excessive speed,
drinking and driving, unsafe road design, and
lack of effective law enforcement and safety
regulations;
□ factors influencing crash and injury severity,
such as the non-use of seat belts, child
restraints or crash helmets, insufficient
vehicle crash protection for occupants and
for those hit by vehicles, and presence of
alcohol;
n factors influencing post-crash injury
outcomes, such as delay in detecting the
crash and providing life-saving measures and
psychological support.
Definitions of key concepts
o Public health approach: a generic analytical
framework that has made it possible for different
fields of public health to respond to a wide range
of health problems and diseases, including
injuries and violence.
o hospital trauma care;
o rehabilitative psychosocial care.
There are risk factors in both pre-hospital and
hospital settings. Post-crash care is covered in
detail in Unit 5.
o Risk: probability of an adverse health outcome,
or a factor that raises this probability.
Key points
o Systems approach: a perspective that takes into
account the various parts and their relationships
as they contribute to the totality of a
phenomenon. In the case of road traffic injury
prevention, this calls for a comprehensive
understanding of the risk factors, determinants,
impacts and interventions, as well as
consideration of the role of different agencies
and stakeholders in prevention.
o A road traffic collision is the outcome of
interaction among a number of factors, some of
which may not appear to be directly related to
road traffic injuries.
o The public health approach is not only helpful in
the analysis of risk factors, but also provides a
framework that guides decision-making for the
entire process, from identifying a problem to
implementing interventions.
o Main risk factors can be categorized into four
groups:
o factors influencing exposure to risk, such as
demographic and economic factors, level of
motorization, and land use planning practices;
o Determinant: a factor which contributes to or
explains the occurrence and prevalence of a
phenomenon.
Questions to think about
o Why is the public health approach a useful
framework in dealing with road safety issues?
o What are the most important risk factors for
road traffic injuries in your local setting?
36 » ROAD TRAFFIC INJURY PREVENTION. TRAINING MANUAL
References
1.
Krug EG Shanna GK. Lozano R. The global
burden of injuries. American Journal of Public
Health. 2000. 90:523-526.
2.
Mercy JA el al. Public health policy for
preventing violence. Health Affairs. 1993:7-29.
3.
Haddon Jr W. Advances in the epidemiology of
injuries as a basis for public policy. Public
Health Report, 1980, 95:411 -421.
4.
Peden M el al. World report on road traffic
injury prevention. Geneva. World Health
Organization, 2004.
5.
Muhlrad N, Lassarre S. Systems approach to
injury control. In: Tiwari G Mohan D. Muhlrad
N, eds. The way forward: transportation
planning and road safety. New Delhi,
Macmillan India Ltd., 2005:52-73.
Further reading
Haddon W. Baker SP. Injury control. In: Clark DW,
MacMahon B, eds. Preventive and community
medicine. Boston. Little-Brown and Company.
1981:109-140.
Haddon W Jr. A logical framework for categorizing
highway safety phenomena and activity. Journal of
Trauma, 1972, 12:193-207.
Tiwari G. Transport and land-use policies in Delhi.
Bulletin of the World Health Organization, 2003.
81(6):444-450.
Trinca G et al. Reducing traffic injur)’: the global
challenge. Melbourne, Royal Australasian College
of Surgeons, 1988.
Notes
38 » ROAD TRAFFIC INJURY PREVENTION; TRAINING MANUAL
Trainee's evaluation o? Unit 2: Risk tactors for road traffic injuries
This form is to be completed by the trainee at the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
1.
To what extent did you achieve the objectives set for this unit? (Please check once using “X” for each
objective)
Objectives
Completely
successful
Completely
unsuccessful
Generally
successful
Discuss the basic elements of the public
health approach and Haddon matrix.
Apply the principles of a systems
approach to the analysis of risk factors
for road traffic injuries.
Discuss the key risk factors for road
traffic injuries.
Relate these risk factors to your country,
region and city.
2.
What is your overall rating of the content presented in this unit? (Please check one using “X”)
Scale
Excellent
Better than expected
Satisfactory
Below' average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
b)
If yes. in what ways were they helpful? What improvements do you suggest?
c)
If no, what were the shortcomings? What suggestions do you have to make them helpful?
5.
What did you like most about the unit?
Unit 2. RISK FACTORS FOR ROAD TRAFFIC INJURIES « 39
6.
What did you like least about the unit?
7.
What did you learn most from this unit?
8.
Explain how your organization, community, city and country, and other interested parlies will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
References
Further reading
Notes
TrninAA'^ Avnluntinn
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION » 43
Overview
o be effective, decision-making and
planning interventions for road traffic
injury prevention should be based on evidence,
not on guesswork. This unit discusses the
importance of evidence for planning and
developing strategies to prevent road traffic
injuries. It justifies the need for evidence, as well
as discussing aspects of collecting and analysing
data, research capacity and other issues.
Objectives
By the end of this unit, the trainee should be able
to:
□ state al least three reasons why evidence is
important in efforts to prevent road traffic
injuries;
o describe the main sources of data and
evidence on road traffic injuries;
o discuss the different methods used to collect
and analyse data on road traffic injuries;
« explain the importance of research and
research capacity in road traffic injury
prevention;
o explain ethical issues in research on road
traffic injury prevention;
o evaluate the quality of data and evidence on
road traffic injury prevention in the trainee’s
own country.
Why coilect data and bui!d
evidence on road traffic injuries?
Rational decision-making in public policy,
including road safety issues, should be dependent
on evidence. Road traffic injury prevention is of
concern to many individuals, groups and
organizations, all of whom require data and
evidence. Different people have their own opinions
on what could make the roads safer, but policy
decisions for effective road traffic injury
prevention need to be based on reliable data and
evidence of what works. We put emphasis on sound
evidence, because limited resources will be wasted
if they are spent on measures that are not effective
or have very' limited impact. Road safety policies
and programmes should therefore be based on
reliable and valid evidence. This is not just about
collecting data on road traffic injuries; it is also
about using the best validated evidence on
intervention measures. In fact, there is a need to
ensure the reliability not only of the data collected,
but also of the methods and instruments used to
collect and analyse information to generate
evidence.
Reliable data and evidence are essential for:
o describing the burden of road traffic injuries;
o assessing risk factors;
o establishing priorities and allocating resources
for prevention of road traffic injuries;
o developing and evaluating interventions;
o providing information for policy-makers and
decision-makers;
o raising awareness.
Sources and types of data
Police departments and hospitals provide most of
the data used in road traffic injury prevention. In
addition to the sources indicated in Table 3.1, data
are also available from published documents, such
as journals, books and research reports, as well as
on the Internet. As a professional in road traffic
injury prevention, you can draw on data and
evidence from many published sources and from
the “grey literature”.
A growing source of information are the
systematic and comprehensive reviews of road
traffic injuries. These reviews synthesize and
summarize evidence from research on specific
topics. Some are global and others are specific to
selected regions and issues. Examples of such
reviews are:
o Odero. Garner and Zwi who conducted a review
of road safety research in developing countries
(2)\
o Nordberg who reviewed the status of knowledge
on injuries (including road traffic injuries) in
Sub-Saharan Africa (J);
o Reviews on such topics as alcohol ignition
interlock programmes, helmets and pedestrian
education that have been conducted by the
Cochrane Injuries Group (4, 5, 6);
44 . ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
TABLE 3.1
Key sources of data on road traffic injuries
Source
Type of data
Observations
Police
Number of road traffic incidents, fatalities
Level of detail varies from one country
and injuries
to another.
Type of road users involved
Police records can be inaccessible.
Age and sex of casualties
Underreporting of injuries is a common problem
Type of vehicles involved
in all countries, particularly in low-income and
Police assessment of causes of crashes
middle-income countries.
Location and sites of crashes
Prosecutions
Health facility settings
Fatal and non-fatal injuries
Level of detail varies from one health care facility to
(hospital inpatient records,
Age and sex of casualties
another.
emergency room records,
Costs of treatment
trauma registries, ambulance
Injury data may be recorded under "other causes”,
making it difficult to extract for analysis.
or emergency technician
records, health clinic records,
family doctor records)
Insurance firms
Fatal and non-fatal injuries
Access to these data may be difficult
Damage to vehicles
Costs of ciaims
Other private and public
Number of fatal and non-fatal injuries
These data may be specific to the planning and
institutions, including
occurring among employees
operation of the firms
transport companies
Damage and losses
Insurance claims
Legal issues
Operational data
Government departments
Population denominators
and specialized agencies
Income and expenditure data
analysis of road traffic injuries
collecting data for national
Health indicators
The data are collected by different ministries and
planning and development
Exposure data
organizations, though there may be one central
Pollution data
agency that compiles and produces reports, such as
Energy consumption
statistical abstracts, economic surveys and
Literacy levels
development plans.
Special interest groups
Number of road traffic incidents,
The various organizations have different interests.
(research institutes, advocacy
fatal and non-fatal injuries
nongovernmental organizations,
Type of road users involved
victim support organizations,
Age and sex of casualties
transport unions, consulting
Type of vehicles involved
firms, institutions involved in
Interaction of victims with vehicles
road safety activities,
Causes
and others)
Location and sites of crashes
Social and psychological impacts
Interventions
Source: reproduced from reference /.
These data are complementary and important for
IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION
Elvik and Vaa who assembled information from
more than 1700 studies on the effects of road
safety measures, covering land use planning,
road safety audits, provision of medical
services, road design, road maintenance, traffic
control, vehicle design, vehicle inspection,
requirements for drivers, road user education
and enforcement (7).
Activity
Task
Based on Table 3.1, describe the status of at least
two of the sources of data on road traffic injuries
available in your country.
Expected results
The purpose of this exercise is to help trainees
review the kind of data collected and kept by
different agencies in their countries. Trainees are
expected to comment on how adequate the data
are and if this information is made readily
available to users.
Injury surveillance systems
Injury surveillance is ongoing systematic collection,
analysis and interpretation of health data essential to
the planning, implementation and evaluation of
health practice, closely integrated with the timely
dissemination of these data to those who need to
know. The final aspect of the surveillance chain is in
the application of these data to prevention and
control (8). A surveillance system includes capacity
for collecting data, analysing them and
disseminating them for public health interventions.
There are several types of surveillance systems.
These can be universal (whole population), based
on sampling (e.g. one week of each month), based
on registries, or based on settings or jurisdictions.
An injury surveillance system is a subset of
surveillance that is specific to different types of
injuries. It is a useful source of injury data routinely
collected in the health-care setting and by other
agencies or institutions. It therefore presents the
first approach to obtaining data on road traffic
injuries. Several steps are needed to create a
successful injury surveillance system (Box 3.1).
BOX 3.1
Designing and building a surveillance system
Key steps, in order, include:
o Identification of stakeholders. Identify agencies that need information on injuries to set
prevention priorities and to evaluate their work. Agencies should not only be within the
health sector, as much injury information is actually collected within other sectors such as
transport or police.
o Definition of the objectives of the system. These objectives should address why studying a
particular injury problem or group of injury problems is necessary; the type of surveillance
to be used should be defined.
o Definition of a case. This definition determines whether or not events will be counted or
classified in one way or another: different sectors and disciplines frequently define cases
differently. Arriving at a common definition of a case is thus essential.
o Identification of data sources. Quality and reliability of sources need to be considered.
o Assessment or evaluation of the existing resources to be used by the system. Evaluate the
expertise of the personnel, the existence of adequate technological and logistic resources, as
well as the actual functioning of the agencies involved. The environment where data are
gathered is also important, not only to ensure completeness and reliability, but also for
providing injured people or their relatives with the best possible environment in which to
address their needs.
46 ° ROAD TRAFFIC INJURY PREVENTION; TRAINING MANUAL
BOX 3. J (continued)
o Inclusion and participation of stakeholders all along the process. Agency involvement in
decision-making processes can improve the functioning of the system by addressing and
responding to agency-specific concerns.
o Definition of data needs. Define what types of variables will or will not be collected.
There are some basic or core minimum data that need to be collected for an injury
surveillance system to be effective.
o Collection of data. Data collection needs to start once the preceding steps have been taken.
A good strategy to save time and resources is to build surveillance systems on already
existing sources of information. If the use of multiple independent systems is involved, then
interagency agreements will be necessary, and adequate conceptual and technical knowledge
on linkage of information will be needed.
o Establishment of a data processing system. This includes the creation of written protocols for
data collection and transmission, and defines whether these operations will be done manually
or electronically. Data processing is best done electronically, and can use software that is
readily and freely available. Analysis of the data implies that technical expertise for this
purpose already exists among the surveillance system personnel.
o Design and distribution of reports based on the analysed data. Frequent reporting can keep
stakeholders up to date on injury issues relevant to them. These reports are the means by
which results are conveyed to stakeholders. In general, they should be produced and
distributed regularly, at least quarterly.
o Training of staff and activation of the system. Training should occur at three levels, with
everyone taking the first level and selected individuals taking the other two. The first level
of training should include basic concepts of epidemiology and surveillance, and an overview
of the system. The second level should include detailed review of forms, with emphasis on
the categories of data and coding, and knowledge on required procedures to obtain the data,
including confidentiality guarantees. The third level should include hands-on practice in
extracting information, coding it and transmitting it. The activation of the system can actually
be conducted as part of an exercise, thus allowing people to get acquainted with all the
procedures and work routines.
o Monitoring and evaluation of the system. This should be continuous and should address any
gathering, reporting or analysis problems. A feedback process is required to inform those
responsible lor data collection of the strengths of the data collected and any deficiencies that
require attention.
All steps indicated above are directed towards using the results to plan interventions. This
is the ultimate purpose of a surveillance system. Having a surveillance system for the sake of
having information is a waste of resources. This information must be shared and must be
provided as a basis for key persons to make informed decisions on what are the best health
options for the population.
Source: references 8. 9
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION » 47
Most countries have some form of national
system for aggregating data on road traffic crashes
using police records or hospital records, or both.
However, the quality and reliability of data vary
between surveillance systems in different
countries. For road traffic injuries, certain key
variables need to be collected. WHO's guidelines
for developing and implementing injury
surveillance systems in hospital settings contain
recommendations on the core minimum data set
and supplementary data that should be collected on
all injury patients, including road traffic casualties
(8). These include age, sex, place of injury, activity
at time of injury, mode of transport, road user,
alcohol use, and nature of injury.
Community-based surveys
A second approach to gathering data on road traffic
injuries is to conduct community-based surveys
(sometimes called household surveys). Some
injured patients fail to reach hospitals for a variety
of reasons, in which case they will not be registered
in hospital-based injury surveillance systems.
Community-based surveys offer useful information
on injuries. WHO has developed guidelines for
conducting community surveys on injuries and
violence, which
provide a standardized
methodology for carrying out such studies (10).
Community surveys have the advantage that they
can be designed for local needs and adapted to
resources available. Such surveys provide more
comprehensive data on injuries in a defined
population or setting, and can help in prioritizing
problems at hand and getting the attention of local
stakeholders.
Studies on selected themes
A third approach is to conduct studies on particular
themes related to road traffic injuries and
transport. Examples are road user surveys,
roadside surveys, origin-destination surveys.
pedestrian surveys, cyclist surveys and speed
surveys - as well as studies on such issues as
alcohol use and the cost of crashes. Different
designs can be used (Box 3.2). These studies may
arise from the need for specific information that is
not available from surveillance systems or
BOX 3.2
Examples of epidemiological siodies
Two examples of epidemiological studies are case-control and cohort studies.
Case-conti-ol studies
A case-control study is an analytic study in which the researcher identifies persons with a
specific injury or condition (the outcome) and selects a comparison group consisting of persons
without the injury. The proportion of each group with evidence of a particular exposure (for
example, motorcyclists wearing helmets) is then compared.
Cohort studies
The cohort is made up of two groups: the target individuals who have a particular exposure and
the comparison individuals who do not have that particular exposure. The study follows the
cohort over a defined period of time. Cohort studies are generally not used when the outcomes
are rare or if they occur long after exposure. Another difficulty of cohort studies is that
individuals are likely to drop out before the study is completed for reasons such as changing jobs
or moving to another town.
Source, references 11.
48 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
BOX 3.3
In-depth crash analysis
While primary level data are useful, such data are generally not adequate for evaluating the
effectiveness of changes in road or vehicle design or enforcement methods. For such
evaluations, it is necessary to conduct special studies and collect data in much greater detail than
available from primary sources. These in-depth studies require people specially trained for the
task.
After a particular problem or safety target has been identified (in terms of a geographical
area, a road location, a type of incident, or a group of road-users involved), a representative
sample of crash reports is drawn from the police or court records, covering one or two recent
years. The sample size required is based on the prevalence of the risk factors to be considered,
along with features such as the ability to make comparisons between different road types,
regions, and road users. Advice of a statistician is necessary to determine how large the
sample needs to be.
Each crash process is reconstructed separately, by one to three people, using a
multidisciplinary approach. Objective data are used as a framework against which to assess and
interpret the verbal accounts provided by the road users involved and the witnesses. The more
incomplete the crash record, the more interpretation will be necessary. Often, field visits to
typical crash locations may be necessary to check some factors related to infrastructure or
current behaviour. In order to obtain reliable results, practical training of the multidisciplinary
team is important.
Because the data used are not intended for diagnostic purposes, some uncertainty remains
in most reconstructions of crash processes: in some cases, several possible scenarios could
explain how a crash occurred, and the various factors identified in these scenarios are
considered as probable rather than definite. After the crash-generating processes have been
reconstructed for the whole sample and the main probable factors identified, these are
aggregated to identify the most prominent ones that corrective measures should primarily seek
to address.
Source, reference 11.
community surveys. Questionnaires are the most
common survey instruments. Other approaches
include direct observations, physical examinations,
laboratory tests, and environmental measurements.
In-depth crash analysis and complementary
investigation can also be undertaken (Boxes 3.3
and 3.4).
Linking and sharing data
Road traffic injury data and evidence are collected
and stored by a range of agencies. This is in itself a
positive feature, as it reflects the multisectoral
nature of the problem. However, it also raises
important issues to do with access, harmonization
and linkages between different data sources and
users. Ideally, where there are a number of data
sources available, it is important that the data
should be linked, to obtain maximum value from
the information. However, for many countries,
especially those with a number of systems at the
local level, this is not always the case. A major
problem is coordination and sharing of information
among different users. While there are usually
issues of confidentiality and other legal restrictions
involved, ways should be found of summarizing
the relevant information and making it available,
without violating any legal prohibitions.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION ° 49
BOX 3.4
Complementary investigations
Complementary investigations are needed to further explain or verify the conclusions of road
crash analysis. The investigations should focus on:
o road surveys of hazardous crash locations, aimed at verifying that items of road design or of
behaviour, identified from crash analyses as probable causal or risk factors, are real and
relevant;
o road inventories, aimed at identifying the most cun-ent defects in road design and
maintenance that may be dangerous and, more specifically, at identifying the items in the
road environment that may be causal or risk factors, and checking their location and
frequency;
o on-the-road vehicle surveys, aimed at assessing the quality of safety-oriented components of
vehicle fleets.
o behavioural observations, aimed at assessing the frequency of dangerous behaviours
identified from in-depth crash analyses, and at understanding their determinants;
o general road-user surveys, aimed at describing public opinions and attitudes towards traffic,
safety conditions and safety rules, and at relating them to crash characteristics and factors, in
order to be able to improve road-user information and education;
o
specific road-user surveys, aimed at clarifying particular risk factors by quantifying
exposure;
o specific road-user surveys, aimed at assessing the public acceptance of specific measures.
Source: reference 11.
Dafia processing, analysis and
dissemination
Data collected from primary and secondary sources
need to be analysed to answer such questions as:
o What are the most common causes and types of
road traffic injuries in different age groups?
o What are the characteristics of persons who are
injured?
a What are the circumstances under which road
traffic injuries are most likely to occur?
o What policies and programmes can reduce the
likelihood and severity of road traffic injuries?
Analysing data, producing regular outputs and
disseminating information on road traffic injuries
are all vital activities. For the purposes of data
analysis, there are various software packages
available, for example Epi Info and Statistical
Package for Social Scientists (SPSS). These
packages can build automatic validity checks and
quality control into the data management process.
Software packages also provide powerful analysis
features for diagnosing problems, enabling rational
decisions to be made on priorities for intervention.
It is necessary to share and disseminate data
and evidence on road traffic injuries with
colleagues, other researchers, policy-makers,
victims, and the community at the local, national
and international levels. Though writing reports
and articles is central to research, this should not be
an end in itself. Information systems on road traffic
injuries need to allow all appropriate outside bodies
access and ensure that the information is effectively
distributed. The design of databases should
therefore take account of the principal needs of
their users, providing high quality data without
overburdening those collecting the data. Databases
50 o ROAD TRAFFIC INJURY PREVENTION, TRAINING MANUAL
also require sufficient resources to ensure their
sustainability. Countries should collaborate and
help support regional and global systems, so that
the monitoring and evaluation of road safety can be
improved and sustained.
Data issues and concerns
There are a number of issues and concerns about
road traffic injury data. These are summarized
below.
Indicators
Indicators are important not just for measuring the
magnitude of a problem but also for setting targets
and assessing performance. The most frequently
used absolute and relative indicators for measuring
the magnitude of the road traffic injury problem are
presented in Table 3.2. There is still a need for these
measures to be refined and for new ones to be
explored. Road traffic injury measures need to take
into account other changes taking place that can
TABLE 3.2
Exomples of commonly used indicators of the road traffic injury problem
Use and limitations
Index
Description
Number of injuries
Absolute figure indicating the number
Useful for planning at the local level for emergency
of people injured in road traffic crashes
medical services
Injuries sustained may be serious or slight
Useful for calculating the cost of medical care
Not very useful for making comparisons
A large proportion of slight injuries are not reported
Number of deaths
Absolute figure indicating the number
Gives a partial estimate of the magnitude of the
of people who die as a result
road traffic injury problem, m terms of deaths
of a road traffic crash
Useful for planning at the local level for emergency
medical services
Not very useful for making comparisons
Fatalities per 10 000 vehicles
Relative figure showing ratio of fatalities
to motor vehicles
Shows the probability vehicle involvement in fatal
crashes
A limited measure for assessing safety in a society
because it omits non-motorized transport and
other indicators of exposure. Usually declines with
motorization
Fatalities per 100 000
Relative figure showing ratio of fatalities
Shows the impact of road traffic crashes on human
population
to population
population as a public health problem
Useful for comparing road traffic injuries as a
health problem in different communities
Useful for estimating severity of crashes
Fatalities per vehicle-kilometre
Number of road deaths per billion
Useful for some international comparisons,
travelled
kilometres travelled
decreases with motorization
Disability-adjusted life
Measures healthy life years lost to
DALYs combine both mortality and disability
years (DALYs)
disability and mortality
Does not take into account non-motorized travel
DALYs do not include all the health consequences
One disability-adjusted life year (DALY)
associated with injury, such as mental health
lost is equal to one year of healthy life
consequences
lost, either due to premature death or disability
Source: reproduced from reference 1.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION ° 51
indirectly affect road traffic injury, such as
increases in population and in transport. When
monitoring safely, changes in transport, movement
patterns and motorization are important.
Two very common indicators are the number of
deaths per 100 000 population, and the number of
deaths per 10 000 vehicles. However, both of these
indicators, have limitations regarding their
reliability and validity that place restrictions on how
they can be used and interpreted. The number of
deaths per 100 000 population is widely used with
reasonable confidence to monitor changes over time
in "personal risk” levels and to make comparisons
between countries. Errors in population statistics are
assumed to have little impact on the observed
changes or comparisons. The number of deaths per
10 000 vehicles relies on vehicle registerations as an
estimate of motorization. However, it is more
problematic as there can be errors in country
databases because of delays in adding or removing
records of vehicles. Furthermore, changes in vehicle
numbers do not generally provide a good estimate
of changes in exposure to risk on the road network,
especially when making comparisons between
countries. An example from Malaysia in the use of
these two indicators is presented in Figure 3.1. The
figure shows that since 1975 Malaysia has
experienced a continuous decline in deaths per 10
000 vehicles, whereas the rate of deaths per 100 000
population has shown a slight increase. Over the
same period, there has been a rapid growth in
motorization and increased movement among
Malaysia’s population. The opposing trends in the
two indicators reflect the fact that road traffic
fatalities have increased more slowly in Malaysia
than the growth in the vehicle fleet, but that they
have increased a little faster in recent years than the
growth in the population.
Activity
Task
Using the example presented in Figure 3.1, draw
graphs showing the trend in fatalities per 10 000
vehicles and fatalities per 100 000 persons for any
country of your choice. The trainer is expected to
provide data on motor vehicles, population and
road traffic fatalities for a period of at least 10
years for selected countries. Where possible, the
trainer should ask trainees to look for the data
before the training session. This may be possible in
situations where trainers have contact with trainees
several days before the training session.
Expected results
This exercise seeks to give trainees a practical
exercise to compute the two indicators, draw
graphs and describe the trends that emerge.
Definitions and standardization of data
There are a number of potential problems with the
definitions of a road traffic death or injury, arising
from:
o variations in the interpretation of the
specified time period;
□ the actual interpretation of the
definition in different countries and
by different people recording the
information;
o differing levels of enforcement;
o differing techniques for assessing
the severity of injuries.
The most commonly cited
definition of a road traffic fatality is;
“any person killed immediately or
dying within 30 days as a result of an
injury accidenf’f 12). However, a recent
study has revealed considerable
variations in working definitions of the
period used to define a road traffic
52 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
fatality. For example, in the European Union,
Greece. Portugal and Spain use 24 hours, France
uses 6 days, Italy uses 7 days, and the other
countries use 30 days (13). To adjust for this
variation, correction factors are applied to arrive at
a 30-day equivalent. However, such factors
introduce uncertainty as to what the real numbers
would be at 30 days.
There are a number of other problems of
definition relating to the classification of injury,
including:
o the method of assessment:
o the location of a fatal crash - whether on a
public or private road;
o the mode of transport - with some
classifications emphasizing the presence of at
least one moving vehicle;
o the source reporting the data - whether police or
a self-report;
b
whether or not to include confirmed suicides;
o whether or not postmortem examinations are
routinely conducted on road traffic deaths.
Problems of definition also arise with regard to
survivors of road traffic crashes, including:
o the actual definition and interpretation of a
serious injury in different countries;
o whether the police, who record most of the
information, are sufficiently trained to ascertain
and correctly assign injury severity.
Road traffic injury and death data can be
missed by the data collection system because of
different definitions used in different countries and
contexts. This highlights the need for definitions to
be standardized and applied across different
countries and settings.
Underreporting
Underreporting of both deaths and injuries is a
major global problem affecting not only lowincome and middle-income countries but also highincome ones. Underreporting can arise from:
o a failure on the part of the public to report:
o the police not recording cases reported to them;
• hospitals not reporting cases presenting to them;
o an exemption for certain institutions, such as the
military, from reporting directly to the police;
o victims sometimes being unable to afford to
attend hospital, especially in some low-income
and middle-income countries.
The problem of underreporting highlights a
number of other structural, methodological and
practical issues affecting the quality of data
collected on road traffic injuries, including:
o the coordination and reconciliation of data
between sources;
o the harmonization and application of agreed
definitions - especially the definition of a road
crash fatality;
o the actual process of classification and the
completion of data forms.
These problems make it difficult to obtain
reliable estimates of road traffic fatalities and
injuries worldwide, and also for certain countries.
Harmonization of data at the national and
international levels can be facilitated by adopting
international definitions. The International
Classification of Diseases (ICD-10) (14) and the
Abbreviated Injury Scale can be used for non-fatal
road crash injuries (15). Agreements to adhere to
regional systems such as the International Road
Traffic Accident Database and the Asia-Pacific
Road Accident Database will encourage uniformity
of definitions.
Other issues
Studies have uncovered a number of other
problems related to road traffic injury data and
evidence. These include:
o missing information within individual records;
o the unavailability of certain specific data - for
example, the crash location, type of injury, and
identification of the vehicle in which the
casualty occurred;
o the scientific soundness of the methods used;
o inadequate quality control;
o lack of data collection on cycling and walking in
transport information systems;
o lack of data on exposure;
o the accuracy and completeness of police
assessment of cause ofcrash;
o lack of rigorous evaluation of interventions,
particularly in low-income and middle-income
countries.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION ■> 53
Research and research capacity
Research forms the basis for generating data and
evidence for informed and effective decision
making. Developing research capacity nationally
is important for road traffic injury prevention
(Boxes 3.5, 3.6, 3.7). Without research capacity,
there
exist
few
means
to
overcome
misconceptions and prejudices about road traffic
injuries (1). National and community research - as
opposed to solely relying on international research
- is important for identifying local problems and
localized groups who are at increased risk of road
traffic injuries. It also helps to ensure a cadre of
national and local professionals who can use
research findings to assess the implications for
policy and programmes. The national evaluation
effort needs to be led by research professionals.
since it is only through implementation and
thorough evaluation that effective programmes
evolve. The independence of research and its
separation from the executive function in
developing public policy is necessary for ensuring
quality, and it protects the research body against
political pressures.
Ethical issues in road traffic injury
research
Research into road traffic injuries must take into
consideration ethical issues. Research ethics deals
with questions concerning the professional and
moral responsibility of the researcher in relation to
the subjects of study, the research sponsors, the
general public, and his or her own beliefs. A conflict
of interest can easily arise because of the values and
interests of different groups involved in research. It
must be noted that each of the stages of the entire
BOX 3.5
What are some of flhe research needs in Hue area of road traffic
injury prevention?
There are many research-related needs for road injury prevention but there is a pressing need
for better collection and analysis of data to enable more reliable estimates to be made of:
o the burden of road traffic injuries on different road users;
® the economic and social impacts of road traffic injuries;
o the effectiveness of specific interventions for road traffic injuries;
o the adequacy of design standards and guidelines for intercity roads carrying mixed traffic.
Tire following specific areas require research:
o how best to assess the effectiveness of packages of road safety measures combining different
actions — such as area-wide traffic calming and urban design;
o the interaction between transport planning and urban planning, and how these affect road safety;
o the design of roads and traffic management, taking into account traffic environments and
traffic mixes encountered in specific locations;
o how various types of successful preventive measures can be transfeired between countries with
differing socioeconomic conditions and differing rates of motorization and traffic mixes;
o how improvements in post-impact care can be made at an affordable cost;
o mechanisms causing head injury and whiplash injury in road crashes, and treatments for
these injuries;
o how to harmonize to incompatibility between vehicles of different sizes involved in crashes
• how to manage exposure to risk — the least-used strategy.
Source: reference 1.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION ■> 53
Research and research capacity
Research forms the basis for generating data and
evidence for informed and effective decision
making. Developing research capacity nationally
is important for road traffic injury prevention
(Boxes 3.5. 3.6. 3.7). Without research capacity,
there
exist
few
means
to
overcome
misconceptions and prejudices about road traffic
injuries (/). National and community research - as
opposed to solely relying on international research
- is important for identifying local problems and
localized groups who are at increased risk of road
traffic injuries. It also helps to ensure a cadre of
national and local professionals who can use
research findings to assess the implications for
policy and programmes. The national evaluation
effort needs to be led by research professionals.
since it is only through implementation and
thorough evaluation that effective programmes
evolve. The independence of research and its
separation from the executive function in
developing public policy is necessary for ensuring
quality, and it protects the research body against
political pressures.
Ethical issues in road traffic injury
research
Research into road traffic injuries must take into
consideration ethical issues. Research ethics deals
with questions concerning the professional and
moral responsibility of the researcher in relation to
the subjects of study, the research sponsors, the
general public, and his or her own beliefs. A conflict
of interest can easily arise because of the values and
interests of different groups involved in research. It
must be noted that each of the stages of the entire
[Wffl
Whaf are some of the research needs in the area of road traffic
injury prevention?
There are many research-related needs for road injury prevention but there is a pressing need
for better collection and analysis of data to enable more reliable estimates to be made of:
o the burden of road traffic injuries on different road users;
o the economic and social impacts of road traffic injuries;
o the effectiveness of specific interventions for road traffic injuries;
o the adequacy of design standards and guidelines for intercity roads carrying mixed traffic.
The following specific areas require research:
o how best to assess the effectiveness of packages of road safety measures combining different
actions — such as area-wide traffic calming and urban design;
o the interaction between transport planning and urban planning, and how these affect road safety;
o the design of roads and traffic management, taking into account traffic environments and
traffic mixes encountered in specific locations;
o how various types of successful preventive measures can be transferred between countries with
differing socioeconomic conditions and differing rates of motorization and traffic mixes;
o how improvements in post-impact care can be made at an affordable cost;
o mechanisms causing head injury and whiplash injury in road crashes, and treatments for
these injuries;
o how to harmonize to incompatibility between vehicles of different sizes involved in crashes
o how to manage exposure to risk — the least-used strategy.
Source: reference 1.
54 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
BOX 3.6
Research capacity deveSopment
Tlie development of national research capacity is urgently needed in many parts of the world.
Experience from many countries that have been successful in reducing the incidence of traffic
injuries shows the importance of having at least one — preferably independent — adequately
funded national organization that deals with road safety research. Countries that have
encouraged the development of professional expertise across a range of disciplines at national
level, and regional cooperation and exchange of information, have reaped much benefit.
Developing these mechanisms should be a priority where they do not exist.
In the field of road traffic injury prevention, several types of initiatives can provide models
for capacity development:
o Network development at the institutional level allows for exchange of information, the
sharing of experiences, and the fostering of collaborative projects and research studies.
WHO's Collaborating Centres for Violence and Injury Prevention are one global example of
this model. A regional example is the Injury Prevention Initiative for Africa.
a Another model is to support schemes that allow scientists and professionals to exchange
research ideas and findings, develop proposals, mentor less experienced researchers, and
carry out research directed at policy-making. The Road Traffic Injuries Research Network is
an example of such a framework that focuses on assisting researchers from low-income and
middle-income countries.
o A third model for capacity development is to strengthen university departments and research
institutes so as to generate a critical mass of appropriately trained professionals. The Indian
Institute of Technology (New Delhi) and University Putra Malaysia are examples of centres
with regular training programmes on road safety.
» A fourth model is to strengthen the career development pathways of trained professionals.
This is important both for attracting and retaining valuable human resources. Part of such a
strategy includes establishing positions for road traffic injury prevention in appropriate
ministries - such as those of health and transport, and finding incentives to encourage
professionals in such posts to perform at a high level.
Source: reference 1.
research process may involve ethical considerations,
in addition to scientific issues. There are guidelines
to assist researchers in approaching ethical issues in
a professional manner. These guidelines focus on
relations between researchers and subjects of study,
confidentiality,
anonymity,
accountability,
responsibility and privacy. Researchers need to
follow national guidelines on research ethics. These
are published and available in different countries.
Key points
o Effective decision-making and planning should
be based on evidence, and should not promote
strategies that have no evidence supporting their
effectiveness.
o Reliable data and evidence are essential for
describing the burden of road traffic injuries,
assessing risk factors, establishing priorities for
prevention, developing and evaluating inter
ventions, providing information for policy-makers
and decision-makers, and raising awareness.
o Police departments and hospitals provide most of
the data used in road traffic injury prevention. In
addition, data are also available from published
documents and research reports, as well as on the
Internet.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION » 55
BOX 3.7
Technology and evidence transfer from high-income countries
Transport system priorities developed in high-income countries may not always fit well with the
safety needs of low-income and middle-income countries for a variety of reasons, including the
differences in traffic mix. In low-income countries, walking, cycling, motorcycling and use of
public transport are the dominant transport modes. In North America and Europe, car ownership
is high, there are between two and three people per car, whereas in China and India car
ownership is much lower, about 280 and 220 people per car, respectively. While it is predicted
that car ownership will increase in China and India, it will still remain low in terms of cars per
capita for another 20-30 years. With a low rate of car ownership, there is a much wider mix of
road users — pedestrians, riders of bicycles, motorcycles and three-wheeled vehicles, and
drivers and passengers of cars, trucks, buses, and vehicles pulled by humans and animals. These
modes of transport operate at different speeds. Technology transfer, therefore, needs to be
appropriate for the mix of different vehicle types and the patterns of road use in a particular
place.
Road safety in countries that are in the process of becoming motorized is further hindered
by the perception that current levels of walking, cycling and motorcycling are temporary'. Such
a view may have arisen through imported expertise from developed countries as much as from
domestic sources. This tends to lead to models of infrastructure from developed countries being
adopted to cater to the longer-term transport needs. However, in most low-income countries,
safety should be promoted within existing conditions, and these include: low per-capita
incomes, the presence of mixed traffic, a low capacity for capital intensive infrastructure, and a
different situation as regards Jaw enforcement.
In high-income settings, strategies and programmes for traffic injury prevention generally
require considerable analysis and planning beforehand. Priority should be given to importing
and adapting proven and promising methods from all nations, and to pooling information among
low-income countries as to their effectiveness in the imported settings.
Source, reference 1.
o Since road traffic injury data and evidence are
collected and stored by a range of agencies,
there is a need to ensure access, harmonization
and linkages between different data sources and
users. Ideally, where there are a number of data
sources available, it is important that the data
should be linked, to obtain maximum value from
the information.
o There are a number of areas where road traffic
injury data are often problematic. These include:
integration of sources of data - from police or the
health system; the types of data collected;
inappropriate
use of indicators;
non
standardization of data; definitional issues related
to traffic deaths and injuries; underreporting; and
poor harmonization and linkages between
different sources of data.
o National and community research - as opposed
to relying solely on international research - is
important for identifying local problems and
localized groups at increased risk of road traffic
injuries.
o Research on road traffic injuries, like any other
research activity, must take into consideration
ethical issues.
Definitions of key concepts
o Evidence: proof or the grounds for demonstrating
the validity of a knowledge claim.
56 • ROAD TRAFFIC INJURY PREVENTION TRAINING MANUAL
o Research design: a set of concise, clear
instructions or procedures indicating how to
conduct research.
o Ethics: principles of morality, particularly those
dealing with the rights and wrongs of an action.
such as the rules of conduct for members of a
particular profession.
Questions to think about
a)
b)
c)
d)
Based on your experience, identify any two
major decisions you have made in the past
regarding road traffic injury prevention. Explain
what was the basis for making these decisions.
Did you consider the body of evidence around
this issue when making the two decisions?
Discuss the prevailing situation with regard to
coordination and sharing of data among
agencies that collect information on road traffic
injuries in your country. If you identify limited
coordination and linkage, indicate steps that can
be taken to improve this situation.
There is a general concern about the gap
between evidence and policy implementation.
Does this situation exist in your country with
respect to road traffic injury prevention? If so,
what leads to this? What steps can be taken to
address this situation?
Underreporting of both deaths and injuries is a
major global problem affecting not only lowincome and middle-income countries but also
high-income countries. What is the situation in
your country? What efforts have been made to
address this problem?
3.
Nordberg E. Injuries as a public health problem
in Sub-Saharan Africa: epidemiology and
prospects for control. East African Medical
Journal, 2000 (Suppl.), 77: S1-S43.
4.
Willis C, Lybrand S, Bellany N. Alcohol
ignition interlock programmes for reducing drink
driving recidivism. Cochrane Injuries Group.
(http://www.cochrane.org/reviews/en/ab004168.
5.
6.
Duperrex O, Roberts I, Bunn F. Safety
education of pedestrians for injury prevention.
Cochrane Injuries Group, (http://www.
cochrane.org/rev iews/en/abOO 153 1 .html,
accessed 31 January 2006).
7.
Elvik R. and Vaa T, eds. The handbook of road
safety measures. Amsterdam, Elsevier, 2004.
8.
Holder Y et al., eds. Injury surveillance
guidelines.
Geneva,
World
Health
Organization, 2001.
9.
TEACH-VIP: user’s manual. Geneva, World
Health Organization, 2005.
10.
Sethi D et al., eds. Guidelines for conducting
community surveys on injuries and violence.
Geneva, World Health Organization. 2004.
11.
Tiwari G, Mohan D, Muhlrad N, eds. The way
forward: transportation planning and road
safety. New Delhi, Macmillan India Ltd.,
2005.
12.
United Nations Economic and Social
Council. Economic Commission for Europe.
Working Party on Transport Statistics
(Fifty-fourth session, 11-13 June 2003).
Intersecretariat working group on transport
statistics (IWG). Report TRANS/WP.6/
2003/6, 4 April 2003.
13.
Mackay M. National differences in European
mass accident data bases. In: Gennarelli TA,
Wodzin W, eds. Proceedings: Contemporary
Injury Severity and Outcome Issues, RCOBI
Annual Conference, Lisbon, Portugal, 24
September 2003: 51-55.
References
1.
Peden M et al. World report on road traffic
injury prevention. Geneva, World Health
Organization, 2004.
2.
Odero W, Garner P, Zwi A. Road traffic
injuries
in
developing
countries:
a
comprehensive review of epidemiological
studies. Tropical Medicine and International
Health, 1997: 445-460.
html, accessed 31 January 2006).
Liu B, Ivers R. Norton R, Blows S, Lo SK.
Helmets for preventing injury in motorcycle
riders.
Cochrane
Injuries
Group
(http://www.cochrane.org/reviews/en/ab00433
html, accessed 31 January 2006).
3.
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION o 57
14.
15.
International statistical classification of
diseases and related health problems. Tenth
revision. Geneva. World Health Organization,
1994.
Joint Committee on Injury Scaling. The
Abbreviated Injury Scale: 1990 revision.
Chicago, IL, Association for the Advancement
of Automotive Medicine, 1990.
Further reading
Rosman DL, Knuiman MW. A comparison of
hospital and police road injury data. Accident
Analysis & Prevention, 1994, 26:215-222.
Sabey EB. Accident analysis methodology. Journal
of International Association of Traffic and Safety
Sciences, 1990, 14:35-42.
58 o ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Notes
Unit 3. IMPORTANCE OF EVIDENCE AS A FOUNDATION FOR PREVENTION " 59
Trainee's evaluation of Unit 3: importance of evidence as a foundation
for prevention
This form is to be completed by the trainee at the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
I.
To what extent did you achieve the objectives set for this unit? (Please check once using “X” for each
objective)
Objectives
Completely
successful
Generally
successful
Completely
unsuccessful
State at least three reasons why evidence
is important in efforts to prevent road
traffic injuries.
Describe the main sources of data and
evidence on road traffic injuries.
Discuss the different methods used to
collect and analyse data on road traffic
injuries.
Explain the importance of research and
research capacity in road traffic injury
prevention.
Explain ethical issues in research on
road traffic injury prevention.
Evaluate the quality of data and
evidence on road traffic injury
prevention in the trainee’s own country.
2.
What is your overall rating of the content presented in this unit? (Please check one using “X")
Scale
Excellent
Better than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
60 » ROAD TRAFFIC INJURY PREVENTION. TRAINING MANUAL
b)
If yes, in what ways were they helpful? What improvements do you suggest?
c)
If no. what were the shortcomings? What suggestions do you have to make them helpful?
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you learn most from this unit?
8.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
=51
s
E3
a
(or
.p’Ti
■
....
.
" (osi’lg '
/
o
ip!SS'W«
©
Promoting crash-protective vehicle design
o
Setting and securing compliance with
road safety rules
Activity
The role of education and publicity
Key points
o
Definitions of key concepts
Questions to think about
References
Further reading
Notes
Trainee's evaluation
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES - 63
Overview
nterventions are required lo solve the road
traffic injury problems discussed in the
earlier units. This unit examines the basic
principles for road traffic injury control. It goes
on to identify and discuss examples of specific
interventions that can be implemented in
different settings around the world.
Objectives
By the end of this unit, the trainee should be able
to:
o describe the basic principles of road traffic
injury control;
□ describe specific interventions that can be
implemented in different settings to prevent
road traffic injuries;
a describe a specific road traffic injury problem
for which the trainee can design and
implement an intervention in the trainee’s own
setting.
Bessie principles of road traffic
injury control
Injuries are caused by a transfer of energy between
the human body and the environment. The amount
of damage and the severity of injuries are directly
related to the amount of energy that is available and
exchanged during a crash. Reducing or managing
the excess energy that may contribute to the
occurrence of a crash and the severity of injuries
during the crash is therefore one of the main basic
principles of road traffic injury control. This
approach was first formalized by Haddon in 1973
(1) and is referred to as ten strategies (Box 4.1).
The emphasis of Haddon’s “ten strategies” is on
technological modifications to reduce injuries.
What specific interventions can be
implemented?
There is no standard package of interventions
suitable for all contexts and countries.
Interventions proven in one setting may not easily
be transferable elsewhere, and will require careful
adaptation and evaluation. Where effective
interventions are altogether lacking, scientific
research is needed to develop and test new
measures. Whether in high-income, or low-income
and middle-income countries, there are several
good practices that can be followed (2):
o reducing exposure to risk through transport and
land-use policies;
o shaping the road network for road injury
prevention;
o improving visibility of road users;
o promoting crash-protective vehicle design;
o setting and securing compliance with road
safety rules;
o delivering post-crash care.
Haddon's fen sfrategies for road traffic injury prevention
a)
Prevent the initial aggregation of the particular energy form. This is usually done by
discouraging the use of vehicles and designs that are particularly hazardous and by
encouraging alternative travel modes.
b)
Reduce the amount of energy aggregated. Examples are the setting of speed limits on roads,
making engines which are not very powerful, and installing speed limiters on existing
vehicles.
c)
Prevent the inappropriate release of energy. This can be achieved by designing vehicles and
the environment such that road users do not make mistakes easily, for example, through the
use of better brakes, safer intersections and roundabouts, and skid resistant roads.
64 o ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
BOX 4. ? (continued)
d)
Alter the rate or spatial distribution of release of the energy from its source. Making pointed
and sharp surfaces rounded and flatter distributes the forces over a larger area during an
impact and thus reduces stresses on the body. Vehicles with appropriate crashworthiness
criteria will transfer less energy to occupants.
e)
Separate susceptible structures from the energy being released by means of space or time.
Separate lanes for bicycles and pedestrians reduce the probability of the riders or walkers
being hit by motor vehicles. Daytime curfews for trucks in cities reduce the number of
crashes involving pedestrians.
f)
Interpose a material barrier to separate the released energy from susceptible structures.
Examples are physical road dividers on highways, and bollards and fences between
pedestrian paths and roads.
g)
Modify contact surfaces or basic structures that can be impacted. Padded interiors and
absence of sharp objects prevent injury. Examples include softer car and bus fronts,
breakaway poles on highways, and use of helmets by two-wheeler riders.
h)
Strengthen human beings who are susceptible to damage by the energy transfer. An example
is treatment for osteoporosis of older road users.
i)
Quickly detect and evaluate damage, and prevent its continuation or extension. Damage can
be limited by efficient systems for extraction of victims from vehicles, emergency care, and
management of crash sites.
j)
Carty out all necessary measures between the emergency period immediately following
damage and ultimate stabilization of the process. Such measures include intermediate and
long-term repair and rehabilitation.
Source: reference 1.
to lower-risk modes of transport;
Apart from the delivery of post-crash care,
which is dealt with in Unit 5. examples of the wide
range of interventions that are available are
presented below.
Managing exposure to risk through
transport and land-use policies
o placing restrictions on motor vehicle users, on
vehicles, or on the road infrastructure;
o promoting safety-centred planning, design and
operation of the road network.
Efficient land use
o providing efficient networks where the shortest
or quickest routes coincide with the safest
routes;
Land-use planning practices and “smart growth"
land-use policies - development of high-density,
compact buildings with easily-accessibie
services and amenities - can serve to lessen the
risk exposure of road users. The creation of
clustered, mixed-use community services, for
example, can cut the distances between
commonly-used destinations, curtailing the need
to travel and reducing dependence on private
motor vehicles. The main aspects of land use
that influence road safety include:
• encouraging people to switch from higher-risk
° the
Safety-conscious planning and design of the road
network and of land use is necessary to minimize
the risk of road traffic injuries. Exposure to risk of
road traffic injury can be decreased by strategies
that include:
o reducing the volume of motor vehicle traffic by
means of better land use;
spatial
distribution
of
origins
and
Unit 4. IMPLEMENTING specific interventions to prevent road TRAFFIC INJURIES ‘ 65
destinations of road journeys;
° urban population density and patterns of urban
growth;
o the configuration of the road network;
» the size of residential areas;
o alternatives to private motorized transport.
Trip reduction measures
Measures that may reduce the distance travelled
include:
o improvements to taxi services;
° higher fuel taxes and other pricing reforms that
discourage private car use in favour of public
transport.
Shaping the road network for road
traffic injury prevention
Examples of road design considerations and
strategies that can make a major contribution to
road traffic injury prevention are presented below.
° better management of commuter transport, and
of transport to and from schools and colleges;
Classifying roads and setting speed limits
by their function
o better management of tourist transport;
Many roads have a range of functions, and are used
by different types of vehicles and by pedestrians with large differences in speed, mass of vehicle and
degree of protection. In residential areas and on
urban roads this often leads to conflicts between the
mobility of motor vehicle users on the one hand
and the safety of pedestrians and cyclists on the
other. Classifying roads functionally - in the form
of a “road hierarchy”, as it is known in highway
engineering - is important for providing safer
routes and safer designs. Such a classification takes
account of land use, location of crash sites, vehicle
and pedestrian flows, and objectives such as speed
control.
° bans on freight transport;
o restrictions on vehicle parking and road use;
o making greater use of electronic means of
communication as a substitute for delivering
communications by road.
Encouraging use of safer modes of
transport
Travel by bus and train is many times safer than
any other mode of road travel. Policies that
stimulate the use of public transport, and its
combination with safe walking and cycling, are
thus to be encouraged.
Strategies that may increase the use of public
transport include:
Improving safety of single-lane
carriageways
o improved mass transit systems (including
improvements to routes covered and ticketing
procedures, shorter distances between stops, and
greater comfort and safety of both the vehicle
and the waiting areas);
A range of engineering measures is needed to
encourage appropriate speed and make hazards
easily perceptible. These measures include:
o providing safe walking and bicycling facilities;
o lanes for overtaking, as well as lanes for
vehicles waiting to turn across the path of
oncoming traffic;
o better coordination between different modes
of travel (including the coordination of
schedules and the harmonization of tariff
schemes);
o secure shelters for bicycles;
a allowing bicycles to be carried on board trains,
ferries and buses;
o “park and ride” facilities, where users can park
their cars near public transport stops;
o provision for slow-moving traffic and for
vulnerable road users;
o median barriers to prevent overtaking and to
eliminate head-on crashes;
o better highlighting of hazards through road
lighting at junctions and roundabouts:
o improved vertical alignment;
o advisory speed limits at sharp bends;
o regular speed-limit signs;
66 • ROAD TRAFFIC INJURY PREVENTION; TRAINING MANUAL
o rumble strips;
o the systematic removal of roadside hazards such as trees, utility poles and other solid
objects.
Traffic-calming measures
Traffic-calming consists of techniques such as
those discouraging traffic from entering certain
areas and installing physical speed-reducing
measures, that include:
narrowing of streets;
giving priority to pedestrians and bicyclists;
link closure;
partial street closure;
speed breakers (road humps);
raised pedestrian crossings;
roundabouts;
rumble devices;
chicanes (‘build outs' or ‘kerb extensions’);
speed bumps (Box 4.2).
These measures are often backed up by speed
limits of 30 km/h. but they can be designed to
achieve various levels of appropriate speed. At
speeds below 30 km/h pedestrians can coexist with
o
o
o
o
□
•
o
o
•
o
motor vehicles in relative safety.
Improving visibility of road users
Seeing and being seen are fundamental
prerequisites for the safety of all road users. There
are various ways of improving the visibility of
particular groups of road users. Some commonly
used methods are listed below.
For motorized two-wheelers:
o use of daytime running lights on the front of
motorized vehicles, which improves visibility
while travelling during daylight hours. Some
countries have made the use of daytime running
lights mandatory (Box 4.3).
o use of reflective and protective clothing
(jackets and vests), which increases the
visibility of riders during the night and thus
reduces the probability of a crash. When these
jackets are made with protective padded
material, they can also serve to reduce the
severity of injuries. However, some of these
jackets and vests may be uncomfortable in
warmer climates or prohibitively expensive.
Brightly coloured clothing, extra reflectors on
BOX 4.2
Speed bumps in Ghana: a 8ow=e©sH road safety intervention
The use of speed bumps, in the form of rumble strips and speed humps, has been found to
be effective on Ghanaian roads. For instance, rumble strips on the main Accra-Kumasi
highway at the crash hot spot of Suhum Junction reduced the number of traffic crashes by
around 35%. Fatalities fell by some 55% and serious injuries by 76%, between January
2000 and April 2001. This speed-reducing measure succeeded in reducing or even
eliminating certain kinds ofcrashes, as well as improving the safety of pedestrians. Speed
control bumps and humps have become increasingly common on Ghanaian roads,
particularly in built-up areas where excessive vehicle speeds threaten other road users. A
wide range of materials - including vulcanized rubber, hot thermoplastic materials,
bituminous mixes, concrete and bricks - have been used in the construction of the speed
control areas. Rumble strips are cheap and easy to install. They have been constructed at
potentially dangerous places on the Cape Coast-Takoradi highway, the Bunso-Koforidua
highway and the Tema-Akosombo highway. Speed humps, in contrast, have been laid to
slow down vehicles and improve the safety of pedestrians in the towns of Ejisu and
Besease on the Accra-Kumasi highway.
Source: based on reference 2.
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES » 67
BOX 4.3
Use of daytime running Sights by motorcyclists in Malaysia and
Singapore
In Malaysia, analysis conducted in 1992 revealed that motorcyclists constituted a majority of
the road traffic injuries and fatalities. A nationwide intervention was introduced to encourage the
use of daytime running headlights. This consisted of a three-month educational and publicity
campaign, followed by a compulsory law introduced in September 1992. The intervention did
not have many supporters in the community, and it was thought necessary to evaluate its effect.
A preliminary study showed that the number of visibility-related crashes involving motorcycles
in the six months after legislation was significantly less than the number of such crashes in the
six months before the introduction of the legislation. A subsequent, more extensive study of the
long-term effects found that the use of daytime headlights by motorcyclists reduced visibilityrelated crashes by 29%.
Singapore also has a high rate of motorcycle crashes, and their riders constitute 40%-50%
of traffic-related injuries and fatalities. In recognition of this problem, as of November 1995. the
Singapore Traffic Police made it compulsory for all motorcyclists to switch on their motorcycle
headlights during the daytime. The legislation was accompanied by a publicity campaign and a
study of the effectiveness of the programme. All the cases of road collisions reported to the
Singapore Traffic Police in the years 1992-1996 were analysed. The results showed that the
legislation was effective in reducing the number of fatal and serious injuries.
Source: based on references 3 and 4.
the vehicle or light reflective vests of thin plastic
material may be an alternative.
For four-wheelers:
o adoption and enforcement of laws requiring
daytime running lights.
o use of high-mounted brake lights, positioned on
the back windscreen of cars, giving greater
visibility from the rear.
have the potential to increase visibility.
However, the effectiveness of such measures has
yet to be determined.
o illuminating crosswalks,
including
the
floodlighting of pedestrian crossings and
increased illumination at crosswalks.
Promoting crash-protective vehicle
design
For cyclists and pedestrians:
The following design features can make cars more
crash worthy:
o equipping bicycles with lights, and with front,
rear, and wheel reflectors.
o a strong passenger compartment with crash
absorbing front and back;
o using brightly coloured clothing, accessories
and vehicles, which can make pedestrians, riders
and non-motorized vehicles more visible to all
road users. Orange and yellow colours are
conspicuous both at night and in the daytime.
Bright colours for wheels and rear ends of non
motorized vehicles (e.g. rickshaws) may also
o head-rests to prevent whiplash injury;
o collapsible steering column;
o laminated windscreens fastened to the car to
prevent ejection;
o padded instrument panels;
o door locks that prevent doors from opening
during a crash;
68 • ROAD TRAFFIC INJURY PREVENTION TRAINING MANUAL
o crash-resistant roofs;
• side protection bars on doors;
o front end design to prevent injury to pedestrians
tn crashes, removal of sharp and pointed objects.
Setiing and securing compliance with
road safety rules
Setting road safety rules is an important aspect of
road traffic injury prevention. Attention should be
paid to the following:
o Setting rules should not be an end in itself. It is
important to ensure compliance through
enforcement, information and education.
o Attempts at enforcing road traffic legislation
will not have any lasting effect, either on road
user behaviour or on road traffic crashes unless
the enforcement is continued for a long time.
and is perceived to be so by road users.
o Enforcement levels need to be high, and high
levels need to be maintained, so as to ensure that
the perceived risk of being caught remains high.
o Imposing very strict penalties (in the form of
higher fines or longer prison sentences) does not
affect road-user behaviour and tends to reduce
the level of enforcement.
o Once offenders are caught, their penalties
should be dealt with swiftly and efficiently.
o Using selective enforcement strategies to target
particular risk behaviours and choosing specific
locations both improve the effectiveness of
enforcement.
o Automated means - such as cameras - are costeffective.
o Publicity supporting enforcement measures
increases their effectiveness; but used on its
own. publicity has a negligible effect on road
user behaviour. Il is essential that road users can
observe the actual increase in level of
enforcement activity.
There are risk factors such as speed and
alcohol, discussed in Unit 2, which require
enforcement of road safety rules. These are briefly
summarized here.
Setting and enforcing speed limits
As indicated in Unit 2, speed is a key risk factor in
road traffic injuries, influencing both the risk of a
road crash as well as the severity of the injuries that
result from crashes. High speeds and large speed
differences makes driving situations difficult to
predict and control. The greater the speed, the less
time available for preventing collisions, and the
greater the severity of the consequences when a
collision takes place. Controlling vehicle speed can
prevent crashes from occurring and can reduce the
impact when they do occur, lessening the severity
of injuries sustained by the victims (Box 4.4).
Enacting and enforcing laws on alcohol
impairment
As indicated in Unit 2, impairment by alcohol is an
important factor influencing both the risk of a road
crash, as well as the severity of the injuries that
result from crashes. The frequency of drinking and
driving varies between countries but it is almost
universally a major risk factor for road traffic
crashes. The scientific literature and national road
safety programmes concur that a package of
effective measures is necessary to reduce alcoholrelated crashes and injuries (Box 4.5).
Enacting and enforcing laws on the use of
seat-belts and child restraints
The following can be done to improve seal-belt and
child restraint use:
o Make the use of seat-belts and child restraints
mandatory by law'.
° Strictly enforce these laws, and support
enforcement by public information and
awareness campaigns.
° Encourage primary enforcement (where a driver
is stopped solely for not wearing a seat-belt),
which is more effective than secondary
enforcement (where a driver can only be
stopped if another offence has been committed).
o Set rules requiring use of technological
solutions to encourage belt use. for example,
seat-bell reminders.
0 Use incentive programmes to enhance police
enforcement. In these programmes, seal-belt use
is monitored and seat-belt wearers are
eligible lor a reward. The rewards may range
from a meal voucher or lottery ticket to
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES • 69
BOX 4.4
Effective management and control otf vehicle speed
The following can be done for effective management and control of vehicle speed:
o Set and enforce speed limits;
® Post speed limits so that motorists know what speeds arc expected on different roads or
sections of roads.
Bear in mind that:
o Introduction of speed limits should be accompanied by sustained, visible enforcement of
these limits;
o Speed cameras are a highly cost-effective means of reducing road crashes;
o Speed levels can also be affected by developing a safer infrastructure. This can involve
modifying the road environment to reduce traffic flow and vehicle speed, thereby providing
protection from crashes and reducing injury rates. Such measures include segregating high
speed and low-speed road users, or discouraging vehicles from entering certain areas;
o Traffic-calming measures can be used;
o The transition from high-speed to low-speed roads can create areas of high risk for crashes for example, where vehicles exit motorways. Design features can be used to mark transition
zones on busy roads approaching towns and villages that can influence drivers' speed.
Slower-speed zones are examples of features that are useful in reducing the speed of vehicles;
o Appropriate speed can be imposed on traffic through design features that limit the speed of
the vehicle itself.
Source- based on results summarized in reference 2.
BOX 4.5
What ccatra be done to prevent alcohol-impaired driving?
Below is a summary of things that can be done to prevent alcohol-impaired driving:
o Set blood alcohol limits. The limits should be consistent with current epidemiological
information concerning the relationship between alcohol and crash involvement. Upper
limits of 0.05 g/dl for the general driving population and 0.02 g/dl for young drivers are
generally considered to be the best practice at present;
o Enact laws that establish a lower legal limit for blood alcohol content for younger or
inexperienced drivers than for older, more experienced drivers;
o Enforce drink-driving laws;
o Use breath-testing devices that provide objective evidence of blood alcohol content;
o Enact laws that specify minimum legal drinking-age laws, an age below which the purchase
or public consumption of alcoholic beverages is illegal;
o Enact laws that require installation of “alcohol ignition interlocks” that require a driver to
lake a breath test before starting a car;
• Implement a graduated driver-licensing system for new drivers that sets a period during
which restrictions are placed on any unsupervised driving. These restrictions should include
a prohibition against driving after drinking any alcohol.
Source: based on results summarized in reference 2.
70 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
sizeable prizes such as video recorders or free
holidays.
emerge from the discussions are the need for:
o Encourage the use of the appropriate type of
child restraint. Good protection requires that the
type of restraint used is appropriate for the age
and weight of the child.
o an assessment to determine helmet-wearing
rates, reasons for low use of helmets,
numbers of fatalities and injuries occurring to
motorcyclists;
o Place child restraints correctly. Child seats
should not be placed in front of air bags.
Enacting and enforcing laws malting the
use of crash-helmets mandatory
There are various strategies that effectively address
the problem of head injuries in motorcyclists. They
include:
o development of a strategy to promote wearing
of helmets, including campaigns, making
helmets available, distribution of helmets to
targeted groups, and enforcement of laws
requiring helmets to be worn;
o monitoring and evaluation of helmet use.
o legislation making helmet wearing compulsory,
accompanied by targeted information and
enforcement campaigns - with penalties for
non-use of crash helmets;
o introduction of standards for motorcycle safety
helmets.
In many parts of the world, there are standards
setting out performance requirements for crash
helmets. These standards are most effective when
based on research findings on crash injuries. In
low-income and middie-income countries, it would
Activity
Task
Study the picture below. Explain the steps you
would take to promote the use of helmets by
two-wheeler riders in such a setting.
Expected results
The purpose of this exercise is to assist the
trainees in identifying and discussing some of
the practical issues that have to be examined
when developing an intervention such as
promoting helmet use. This exercise can be done
in groups. Trainees can be pul into groups of
three to four people and asked to discuss what
can be done. Each group should then present the
main points and outcome of their discussion to
the class. Among the key topics that should
©WHO, 2005
be highly desirable for effective, comfortable and
low-cost helmets to be developed, and local
manufacturing capacity increased.
The role oiF education and
publicity
Public health sector campaigns in the field of road
traffic injury prevention have encompassed a wide
range of measures, but education has always
featured as one of the key activities of prevention.
Ongoing research (Box 4.6) and experience have
led to re-examination of the role that education
plays in road traffic injury prevention. The
following are the key conclusions from research on
this issue:
o Informing and educating road users can improve
knowledge about the rules of the road and about
such matters as purchasing safer vehicles and
equipment.
o Basic skills on how to control vehicles can be
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES ° 71
BOX 4.6
Re-examination of road safety education and training:
conclusions from studies
Concerns regarding the effectiveness (or lack of it) of education in promoting road safety have
prompted researchers to do systematic literature reviews on the subject in the past few years. A
summary of the conclusions of these reviews is presented below:
o Education and skill training for children and pedestrians
Education and skill training programmes on bicycle handling for children, and on car
handling and drunken driving for adolescents, for the most part showed no effects, or even
negative effects, on attitude, behaviour, and incidence of injuries. Such training might create
unrealistic beliefs in one's own abilities, and parents might overestimate their children's
abilities, so that they may be exposed to more dangerous situations (5).
Pedestrian safety education can result in improvement in children's knowledge and can
change observed road crossing behaviour but whether this reduces the risk of pedestrian
motor vehicle collision and injury occurrence remains unknown. Changes in safety
knowledge and observed behaviour decline with time, suggesting that safety education must
be repeated at regular intervals (6).
o Driver education
Driver education (school based) leads to early licensing. Results of systematic literature
review provide no evidence that driver education reduces road crash involvement, and
suggest that it may lead to a modest but potentially important increase in the proportion of
teenagers involved in traffic crashes (7).
A systematic review that examined the effects of post-licence driver education found no
evidence of effect on prevention of road traffic injuries or crashes (8). Although the results
are compatible with a small reduction in the occurrence of traffic offences, this may be due
to selection biases or bias in the included trials. Because of the large number of participants
included in the meta-analysis (close to 300 000 for some outcomes) we can exclude, with
reasonable precision, the possibility of even modest benefits.
Drivers who take a theory test have similar crash rates as drivers who do not undergo a theory
test, optional training for motorcycle and moped riders or use of simulators during training
(9).
• Graduated driver licensing systems
Young and inexperienced drivers have higher crash rates (10). Over the past decade
experiments have been done to provide gradual access to driving privileges to new licensees.
These programmes are called graduated driver-licensing systems. Restrictions can include
curfews over driving at night, limits on carrying passengers especially at night. Results from
studies have shown great promise with reductions in crash rates from 5% to 60% (II).
taught.
Education can help to bring about a culture of
concern and develop sympathetic attitudes
towards effective interventions.
o Most programmes providing highway safety
education do not work in isolation - they need to
be linked or used in combination with other
measures.
o There is a need for a balanced approach to the role
72 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
of education and publicity, taking into account
evidence from research on behaviour change, the
interventions that may be promising, those to
avoid, and those to encourage, as well as the need
to implement proven measures.
o General non-specific road safety campaigns
should be avoided. Campaigns should rather be
used to put important questions on the agenda.
and should preferably support other measures
such as new legislation or police enforcement.
The ongoing re-examination of road safety
education is an essentia! aspect of research, and the
emerging conclusions need to be considered and
examined by researchers and practitioners in the
field of road traffic injury prevention. The
conclusions draw attention to the need to be
cautious and avoid focusing on only road safety
education.
Key points
o Injuries are caused by a transfer of energy
between the human body and the environment.
Therefore reducing or managing the excess
energy that may contribute to the occurrence of
a crash and the severity of injuries during the
crash is one of the main basic principles of road
traffic injury control.
o Inappropriate speed: driving at a speed unsuitable
for the prevailing road and traffic conditions.
o Smart growth land-use policies: the development
of high-density, compact buildings with easily
accessible services and amenities.
Questions to think about
o Choose one of the interventions presented in this
unit that has been implemented in the country or
city where you live. Discuss the results that have
been obtained.
o The local authority of your city is planning
interventions to respond to increasing collisions
involving children who live on one side of the
road but have to cross this road to reach a school
on the other side. What interventions would you
recommend? What are the reasons for your
recommendations?
o The majority of people in a certain community
do not wear seat-belts despite the existence of a
law requiring the use of seat-belts. Discuss what
you would do to address this problem.
References
1.
o There is no standard package of interventions
suitable for all contexts and countries.
Haddon Jr W. Energy damage and the ten
countermeasure strategies. Human Factors
1973. 15: 355-366.
2.
o Whether in high-income, or low-income and
middle-income countries, there are several good
practices that can be followed:
Peden M et al. World report on road traffic
injury prevention. Geneva, World Health
Organization, 2004.
3.
Umar RS, Mackay MG, Hills BL. Modelling of
conspicuity-related motorcycle accidents in
Seremban and Shah Alam, Malaysia. Accident
Analysis & Prevention, 1996, 28: 325-332.
4.
Yuan W. The effectiveness of the ‘ride-bright’
legislation for motorcycles in Singapore.
Accident Analysis & Prevention. 2000. 32:
559-563.
5.
Lund J, Aaro LE. Accident prevention:
presentation of a mode! placing emphasis on
human, structural and cultural factors. Safety
Science, 2004, 42: 271-324.
6.
Duperrex O, Roberts I, Bunn F. Safety
education of pedestrians for injury prevention:
a systematic review of randomised controlled
o
reducing exposure to risk through transport
and land-use policies;
o shaping the road network for road traffic
injury prevention;
o
improving visibility of road users;
o
promoting crash-protective vehicle design;
o setting and securing compliance with key
road safety rules;
o
delivering post-crash care.
Definitions of key concepts
o Excess speed: exceeding the speed limit set for
a specific country, city, town, region or road.
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES ° 73
trials. British Medical Journal, 2002, 324:
1129-1131.
10.
Evans L. Traffic safety and the driver. New
York, Van Nostrand Reinhold, 1991.
7.
Roberts I et al. 2003. Preventing child pedestrian
injury: pedestrian education or traffic calming?
Australian Journal of Public Health, 1994, 18:
209-212.
II.
Hedlund J, Compton R. Graduated driver
licensing research in 2003 and beyond. Journal
of Safety Research, 2004, 35: 5-11.
8.
Ker K et al. Post-licence driver education for
the prevention of road traffic crashes: a
systematic review of randomised controlled
trials. Accident Analysis & Prevention, 2005,
37: 305-313.
Further reading
9.
Elvik R, Vaa T, eds. The handbook of road
safety measures. Amsterdam, Elsevier, 2004.
Mohan D, Tiwari G. Road safety in low-income
countries: issues and concerns regarding
technology transfer from high-income countries.
In: Reflections on the transfer of traffic safety
knowledge to motorising nations, Global Traffic
Safety Trust, Vermont South, Australia, 1998:
27-56.
O’Neill B. Role of advocacy, education, and
training in reducing motor vehicle crash losses. In:
Proceedings of WHO meeting to develop a 5-year
strategy on road traffic injury prevention. World
Health Organization, Geneva, 2001: 32-40.
Robertson LS. Injuries: causes, control strategies
and public policy. Lexington Books, Lexington,
MA, 1983.
’
F M T F f f M f f f f ir f f F r f f f f f f f f f f O f f O S f i 1 1
Unit 4. IMPLEMENTING SPECIFIC INTERVENTIONS TO PREVENT ROAD TRAFFIC INJURIES • 75
Trainee's evaluation of Unit 4: Implementing specific interventions to
prevent road traffic injuries
This form is to be filled by the trainee at the end of this unit to assess the content and approach used. This
evaluation is helpful to the trainee, trainer and developer of this manual.
1.
To what extent did you achieve the objectives set for this unit? (Please check once using “X” for each
objective)
Objectives
Completely
successful
Generally
successful
Completely
unsuccessful
Describe the basic principles of road
traffic injury control.
Describe specific interventions that can
be implemented in different settings to
prevent road traffic injuries.
Describe a specific road traffic injury
problem for which the trainee can
design and implement an intervention in
the trainee’s own setting.
’
2.
What is your overall rating of the content presented in this unit? (Please check one using “X")
Scale
Excellent
Better than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
b)
If yes, in what ways were they helpful? What improvements do you suggest?
c)
If no, what were the shortcomings? What suggestions do you have to make them helpful?
76 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you learn most from this unit?
8.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
IF I? IF ff
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Activity
Key points
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References
Further reading
Trainee's evaluation
- •
-■
Unit 5. DELIVERING POST-CRASH CARE o 79
Overview
reventing road traffic injuries from
occurring should be the main goal to be
pursued, but the reality is that crashes continue
to occur. Society therefore has to be prepared to
mitigate the consequences of crashes and
enhance the quality of life of people who are
injured. The aim of post-crash care is to avoid
preventable death and disability, limit the
severity of the injury and the suffering caused by
it. and ensure the crash survivor’s best possible
recovery and reintegration into society. The way
in which persons injured in road traffic crashes
are dealt with following a crash determines their
chances and the quality of survival. In this unit,
we discuss the chain of help for people injured in
road traffic collisions. The unit discusses three
components of post-crash care: pre-hospital,
hospital and rehabilitation.
H
Objectives
By the end of this unit, the trainee should be able
to:
o describe the main actions that need to be taken
soon after a road traffic collision has occurred;
o discuss the key resources and organization
needed for hospital care;
o discuss ways of providing rehabilitation
services to injured persons;
□ examine the quality of post-crash care in the
trainee’s own setting.
Pre-hospitai care
Core components
An effective pre-hospital care system must have
certain core administrative and programmatic
elements (Box 5.1). When available, the existing
emergency medical services of the country or
region should be used and strengthened, with input
from community leaders and members of the
population that they serve. Various structural
models of pre-hospital care systems exist. The one
chosen for a particular setting should take into
account local factors and resources. At the national
level, a lead agency should be designated to
promote pre-hospital trauma care. In some
countries, this role may be played by the ministry
of health, while in others it may rest with the
ministry of the interior, the ministry of transport or
elsewhere. Because pre-hospital trauma care
involves public safety as well as public health,
intersectoral cooperation is essential.
Regardless of how simple or sophisticated a
given pre-hospital trauma care system might be.
certain elements are essential in order to decrease
preventable morbidity and mortality (1). These
elements include, at a minimum, prompt
communication and activation of the system, the
prompt response of the system, and the
assessment, treatment and transport of injured
people to formal health-care facilities when
necessary. Whenever and wherever possible,
existing clinics, hospitals and health services
should be used to ensure efficient mobilization of
health-care resources. This is true for both rural
and urban areas.
First responders
The first and most basic tier of a system can be
established by teaching interested community
members basic first aid techniques. These first
responders can be taught to recognize an
emergency, call for help and provide treatment until
formally trained health-care personnel arrive to
give additional care (Box 5.2). There are many
publications that provide information on good
practices to be followed by lay persons when
providing first responder care (1-3).
It may be possible to identify particularly
motivated or well-placed workers, such as public
servants, taxi drivers, or community leaders, and
train them to provide a more comprehensive level
of pre-hospital care. In addition to learning a more
extensive range of first-aid skills, this group could
be taught the basic principles of safe rescue and
transport. With this level of training, a kit of simple
equipment and supplies (Box 5.3) and access to a
suitable vehicle, these individuals can provide an
acceptable level of trauma care.
80 « ROAD TRAFFIC INJURY PREVENTION. TRAINING MANUAL
BOX 5.1
Key elements in administering a pre-hospital trauma care system
o Lead national agency. Designate a lead national agency to govern the system. This agency's
responsibilities should include legislative development, regulatory supervision, and
organization and financing of the system.
• Support. Ensure that there is regional and local support, and involvement that includes
members of the local community.
• Local administration. Develop local administration and supervision, taking into account the
local context and resources.
o Medical direction. Ensure that the medical director is providing the essential coordination of
care, training and education, and quality improvement initiatives.
» Political support. Develop political and legislative support. These are essential for ensuring
the operational and financial viability of the system.
Source: reference 1.
MM
Role of lay bystanders
Those who are present or who arrive first at the scene of a crash can play an important role in
various ways, including by:
o contacting the emergency services, and calling for help;
o taking action to secure the scene — such as preventing further crashes, preventing harm to
rescuers and bystanders, and controlling the crowd gathered at the scene;
o organizing people and resources, keeping bystanders away from the injured so that helpers
can get on with rescue operations, and organizing people into groups (one group for
comforting the victims, their friends and their relatives, another group for transporting the
patients, and another group for actually administering the first aid);
o helping to pul out any fire;
o applying first aid;
o transporting the injured persons to a hospital if no ambulance is available.
Source: reference 1.
Taking an injured person
io hospital
If you have to take injured patients to hospitals you
have to make sure that during shifting the patients
are not hurt more. You have to move the patients
from where they are lying to carry boards or
stretchers and then to vehicles in which they are
going to be carried to hospitals. Any firm board can
be used for this. If a ready-made stretcher is
available, it should be used, but it is not essential.
What is important is a rigid flat surface which keeps
the spine stable and which allows resuscitation to be
carried out. A stretcher can be improvised from:
o any wooden board or ladder;
° two or three boards tied together;
o bus, van or other flat seats that are long enough.
Unit 5. DELIVERING POST-CRASH CARE « 81
BOX 5.3
First aid and first aid kit
Conventionally, first aid io an injured person includes resuscitation, dressing of wounds and
splintage. In principle, resuscitation at the crash site is similar to what takes place at the hospital.
The "ABC" of resuscitation includes:
o maintenance of a clear airway;
o establishment of breathing;
o establishment or assessment of circulation.
Experience has shown that most of the medicines, antiseptics, bandages and implements usually
found in first aid kits are not necessary for first aid. In fact, if you do not use bandages and
dressings promptly, they usually gather dust containing all kinds of bacterial spores and, if the
air is damp, they will even grow fungi. Some bandages and dressings are sold in sterile bags.
These, too, may grow harmful organisms if they are not checked regularly for damage and for
expiry dates. A clean cloth would be safer and better. The following items could be useful while
you are administering first aid:
• a set of large safety pins to make slings and splints;
o a pair of tweezers to take out splinters and thorns;
o a pair of scissors to cut cloth bandages and dressings;
o soap to wash wounds, to remove grease and dirt, and to wash your hands after you have
administered first aid.
While shifting, the patient’s back, neck and
airway have to be protected from further injury. If
the patient is unconscious, gently place a large
folded cloth or towel under the neck so that the
neck does not sag against the ground.
Ambulances are specifically designed for
carrying patients to hospital. However, the type of
vehicle is not as important as whether it can carry a
patient comfortably and safely. The vehicle should
have enough space to keep the patient’s back
straight, and the person accompanying the patient
should be able to care for and resuscitate the patient
if necessary'. Though rapid transport is important, it
is not possible to go above a certain speed in towns
and cities without endangering the lives of patients
and those outside the vehicle. Speeding could even
cause yet another collision.
At all times during transport, it is important to
keep watch to ensure that the patient’s airway is
clear, the patient is breathing (a clear airway does
not necessarily mean that the patient is breathing),
and that the patient's pulse can be felt. Being able
to feel the pulse means that the heart is beating. A
crash victim may look fine and appear to be
uninjured and it may take some time before signs
and symptoms of injury become obvious.
When the patient is fully conscious and you are
sure that he or she has only a limb injury, then he or
she can be safely taken to hospital in a sitting
position. Take care to splint or protect limb injuries
or stop bleeding. While in the vehicle, try to keep
the injured limb from touching the floor of the
vehicle. Vehicle bumps are easily transmitted from
the floor, and this hurts the patient more. If the
patient has to be carried down a flight of stairs then
the chair-lift can be used.
Basic pre-hospital trauma care
The second tier of care can be provided at the
community level by those who have been trained in
the principles of basic pre-hospital trauma care.
also known as basic life support. These providers
should have formal training in pre-hospital care,
scene management, rescue, stabilization and the
transport of injured people. Those who provide this
basic care form the backbone of formal pre-hospital
trauma care systems.
82 " ROAD TRAFFIC INJURY PREVENTION- TRAINING MANUAL
Advanced pre-hospital trauma care
Legal and ethical considerations
The third-tier care interventions include the
establishment of complex regional call manage
ment centres and highly integrated communication
networks. On a system level, advanced pre-hospital
interventions include call management centres, the
development of integrated wireless communication
networks, and the purchase and maintenance of a
fleet of ground ambulances or air ambulances.
Broadly termed “advanced life support”, clinical
services like these generally require the skills of a
professional pre-hospital care provider - either a
physician or a non-physician paramedic with
professional training.
Recent scientific reviews have questioned
the effectiveness of many medical techniques at
the crash site such as intravenous fluid
administration and endotracheal intubation (4).
Even the efficacy of advanced trauma life
support training in the pre-hospital setting for
ambulance crews has been questioned by
researchers (5). If adopted without regard for
cost, advanced life support programme tech
niques can inadvertently harm pre-hospital
systems by diverting precious resources from
less glamorous but clearly effective inter
ventions that benefit far more people. For this
reason, planners should exercise caution when
considering whether or not to adopt advanced
life support options and to base their decisions
on a clear understanding of the costs of
implementation versus the anticipated benefits.
WHO has recently published a document on pre
hospital trauma care systems that provides
guidance on these issues (1).
Finally, for pre-hospital trauma care systems to
function effectively, certain ethical and legal
principles must be established and followed.
Bystanders must feel both protected to act and
confident that they will not suffer adverse
consequences, such as through legal liability, as
a result of aiding someone who has been injured.
Most of the legal and ethical concepts that
underlie the provision of pre-hospital care are
universally respected, regardless of a country's
religious, ethical and cultural traditions.
Core adminisirative elements
In addition to implementing basic systems of care,
certain administrative elements must be in place to
ensure that a pre-hospital care system is both
effective and sustainable. For example, each
episode of care should be documented, not only
because it is important to monitor the processes and
outcomes of care, but also because incident records
provide important insights into the nature and
location of community hazards and how injuries
might be prevented.
The hospital setting
The key components of the hospital setting are
outlined below.
Human resources
Not all hospitals have the same level of expertise
for managing trauma patients. Unnecessary shifting
from one hospital to another hospital can be
avoided if proper triaging is carried out.
Fortunately, most bystanders make their own
assessment of the injury depending on bleeding and
other subjective judgements, and may decide to
transport patients to hospitals.
There are three categories for triaging trauma
patients:
o Category 1: most seriously injured, based on
physiological or anatomical criteria;
o Category 2: less injured, including the patient at
risk of significant injury based on the
mechanism of injury;
o Other: those not meeting the criteria for
Categories 1 or 2; these patients are handled as
consultations without a trauma alert.
For hospital care to be effective, police
officers and primary care providers must have a
good knowledge of the locations and levels of
expertise of different hospitals in their regions.
The link between primary, secondary and tertiary
centres is essential. The most appropriate
communication technology should be developed
for this purpose, and its availability publicized.
Unit 5. DELIVERING POST-CRASH CARE “ 83
With regard to training, the following needs to be
kept in mind:
o Training for teams managing trauma care is vital
(Box 5.4);
° Short in-service training should be conducted to
strengthen the available human resources;
® There should also be more formal, in-depth
training. This includes improving the traumarelated training received by doctors, nurses and
oilier professionals, both in their basic education
and in postgraduate training.
Physical resources
In addition to human resources, physical resources
are necessary. Many hospitals in low-income and
middle-income countries lack important traumarelated equipment, vital for treating life-threatening
chest injuries and airway obstruction — major
preventable causes of death in trauma patients. Part
of the problem, in some countries, is lack of
organization and planning, rather than restricted
resources. There is a need to address this problem,
including by conducting research on the matter.
Organization of trauma care
A prerequisite for high quality trauma care in
hospital emergency departments is the existence of
a strategy for the planning, organization and
provision of a national trauma system. There is
considerable potential worldwide to upgrade
arrangements for trauma care and improve training
in trauma care at the primary health care level, in
district hospitals, and in tertiary care hospitals.
The Essential Trauma Care Project, a
collaborative effort between WHO and the
International Society of Surgery, aims to improve
the planning and organization of trauma care
worldwide (6). The project seeks to help individual
counties in developing their own trauma services,
to:
o define a core of essential injury treatment
services;
o define the human and physical resources
necessary to assure such services in the best
possible way, given the particular economic and
geographic settings;
o develop administrative mechanisms to promote
these and related resources on a national and
international basis, such mechanisms to include
specific training programmes, programmes to
improve quality, and hospital inspections.
While the goals of the Essential Trauma Care
Project extend beyond the field of road safety, the
success of the project can only be beneficial for
crash-related trauma care.
j
Trauma team training -for rurai needs in Uganda
The trauma team training course in Uganda was jointly developed by the Injury Control Center
in Kampala, and the Canadian Network for International Surgery, in response to the needs of
rural hospitals in Uganda. The course is designed to create trauma teams that can function with
personnel found in under-resourced health centres in Africa. The team normally consists of a
clinical officer, an anaesthetic officer, an orthopaedic technician, a registered nurse and an aid.
The course lasts three days and is delivered through lectures, skill stations and team exercises.
The purpose of the lectures is to ensure that all team members have a common understanding
of key issues in clinical trauma care, and of the importance of working together as a team. The
skill stations assure that all participants can proficiently perform their role in the skills necessary
for the initial care of the injured patient and the preparation of the patient for definitive care. At
the end of the course, the institution gains a cohesive team. Since its inception in 1998, the
trauma team training course has trained over 200 people from rural hospitals in Uganda, and
plans are in place for its translation into Portuguese and Arabic for wider use in Africa.
Source reference 1.
84 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Rehabilitation
For every person who dies in a road traffic crash,
many more are left with permanent disabilities (7).
Rehabilitation services are an essential component
of the comprehensive package of initial and post
hospital care of the injured. They help to minimize
future functional disabilities and to restore the
injured person to an active life within society. Most
countries need to increase the capacity of their
health-care systems to provide adequate reha
bilitation to survivors of road traffic crashes.
High-quality treatment and interventions for
rehabilitation in the period of hospitalization
immediately following an injury are of utmost
importance, in order to prevent life-threatening
complications related to immobilization. However,
despite the best management, many people still
become disabled as a consequence of road traffic
crashes. In low-income and middle-income
countries, efforts should focus on capacity building
and personnel training so as to improve the
management of survivors of road traffic crashes in
the acute phase, and thus minimise the develop
ment of permanent disability.
Medical rehabilitation services involve
professionals from a range of disciplines. These
include specialists in physical medicine and
rehabilitation, as well as in other medical or para
medical fields, such as orthopaedics, neurosurgery
and general surgery, physical and occupational
therapy, prosthetics and orthotics, psychology,
neuropsychology, speech therapy and nursing. In
every case, the recovery of the patient’s physical
and mental health is paramount, as well as the
patient’s ability to become independent again and
reintegrate into daily life.
Medical rehabilitation services also play a vita!
part in the independence and quality of life of
people living with disabilities. Among other things,
these services can provide mechanical aids that
greatly assist affected individuals to be reintegrated
into and participate in ordinary daily activities,
including their work. Such aids, delivered through
outpatient departments or outreach services to the
home, are often essential in preventing further
deterioration. In many countries, once acute
management has been accomplished and mecha
nical aids provided, community-based rehabili
tation remains the only realistic means of
reintegrating the individual into society.
Activity
Task
Based on the information provided in this unit,
prepare a brief summary on the status of the post
crash care system in your setting.
Expected results
This exercise is meant to help trainees conduct a
rapid assessment of the post-crash care system in
their settings. They can do this for the entire
system or selected components.
Key points
o Society has to be prepared not only to prevent
road traffic injuries but also to mitigate their
consequences and enhance the quality of life of
people who are injured.
o Essential elements in pre-hospital care include
prompt communication, treatment and transport
of injured people to formal health-care facilities.
o Existing clinics, hospitals and health services
should be used to ensure efficient mobilization
of health-care resources.
o Human resources, physical resources and
organization are essentia! aspects in hospital
settings.
o Rehabilitation services are an essential
component of the comprehensive package of
initial and post-hospital care of the injured.
o The three components of care - pre-hospital,
hospital and rehabilitation - are interrelated and
form a continuum of care.
Questions io think about
a)
How adequately is your country or city prepared
to respond to post-crash needs of persons
injured in road traffic collisions?
b)
How can you improve post-crash care in your
country?
iU U U iiiiiiO iillO O fc lL lO O O
Unit 5. DELIVERING POST-CRASH CARE ’ 85
traing for ambulance crews. On behalf of the
WHO Pre-Hospital Trauma Care Steering
Committee. The Cochrane Database of
Systematic Reviews 2006. Issue 1. Chichester,
UK. John Wiley & Sons, Ltd., 2006.
References
1.
Sasser S el al. Prehospital trauma care systems.
Geneva, World Health Organization, 2005.
2.
Varghese M, Mohan P. When someone is hurt...
a first aid guide for laypersons and community
workers. New Delhi, Transportation Research
and Injury Prevention Programme. Indian
Institute of Technology, Delhi, 1998.
3.
Werner D. Where there is no doctor. Palo Alto,
Hesperian Foundation, 1977.
4.
Bunn F et al. Effectiveness of pre-hospital
trauma care. On behalf of the WHO Pre
hospital Trauma Care Steering Committee.
Cochrane Reviews, Chichester, UK: John
Wiley & Sons, Ltd., 2001.
5.
Sethi D el al. Advanced trauma life support
6.
Mock C et al. Guidelines for essentia! trauma
care. Geneva. World Health Organization,
2004.
Further reading
Peden M et al. World report on road traffic injury
prevention. Geneva, World Health Organization,
2004.
Pan American Health Organization. Establishing a
mass casualty management system. Washington,
D.C., Pan American Health Organization and
World Health Organization, 2001.
ft; fl fl If fl ft fl fl fl fl
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t t If
:
t
Notes
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86 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Trainee's evaluation of Unit 5: Delivering post-crash care
This form is to be completed by the trainee at the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
1.
To what extent did you achieve the objectives set for this unit? (Please check once using “X” for each
objective)
Objectives
Completely
successful
Completely
unsuccessful
Generally
successful
Describe the main actions that need to
be taken soon after a road traffic
collision has occurred.
Discuss the key resources and
organization needed for hospital care.
Discuss ways of providing rehabilitation
services to injured persons.
Examine the quality of post-crash care
in your setting.
2.
What is your overall rating of the content presented in this unit? (Please check one using “X”)
Scale
Excellent
Better than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
b)
If yes, in what ways were they helpful? What improvements do you suggest?
c)
If no, what were the shortcomings? What suggestions do you have to make them helpful?
88 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you leant most from this unit?
S.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10. What do you think should be dropped from this unit?
Unit 6. MULTISECTORAL COLLABORATION » 91
Overview
Why collaborate?
he World report on road traffic injury
prevention observes that the world faces a
road safety crisis that has not been fully
recognized (I). It points out that international
organizations, donor countries, governments and
nongovernmental organizations have important
roles to play in addressing this crisis and
strengthening road safety around the world. The
report strongly emphasizes the use of a systems
approach to the global road safety crisis. This
refers not only to academic analysis of the
elements or systems that contribute to road
traffic injuries, but also to the need for different
sectors to work together. The report notes that
road safety is a shared responsibility, and calls
for multisectoral collaboration. The need for
collaboration was further stressed in the World
Health Assembly resolution WHA57.10 on road
safety and health (2). which recommends that
WHO Member States should facilitate
multisectoral collaboration between different
ministries and sectors. This unit examines the
role of multisectoral collaboration in road traffic
injury prevention. It discusses the rationale for
collaboration and outlines different forms and
levels of collaboration for road traffic injury
prevention.
The need for collaboration arises from the
diverse nature of the problem of road traffic
injuries. The problem has multiple determinants,
affects many people and sectors, and requires
action by different sectors. Many sectors are
involved in road safety (Figure 6.1) and it is
important for them to collaborate to try and
influence the likely success of road safety
initiatives that are undertaken at national,
regional and international levels. The benefits of
multisectoral collaboration are summarized in
Box 6.1.
H
FIGURE 6.1
The key organizations and players influencing
road safety policy
Objectives
By the end of this unit, the trainee should be able
to:
o explain why there is a need for multisectoral
collaboration to prevent road traffic injuries;
o describe different forms of collaboration for
road traffic injury' prevention at international,
national and local levels;
o discuss the roles that different institutions
involved in road traffic injury prevention can
play;
<s discuss how to effectively use collaboration to
strengthen efforts to prevent road traffic
injuries in his or her own city, region and
country.
What kind of collaboration ran be
developed?
Different forms of collaboration can be developed.
Collaboration can, for example, be organized
around complementary issues at international.
regional, national and local levels. The issues might
be research, information sharing, implementation
of interventions, policy development, advocacy.
support to victims and their families, fund-raising
and capacity development. Collaboration can also
be formal or informal. We provide examples of
these forms on the next pages.
92 • ROAD TRAFFIC INJURY PREVENTION- TRAINING MANUAL
Who'S can collaboration in road safety deliver?
o increased access to resources
o
o
o
o
o
o
o
more efficient use of resources
enhancement of accountability
development of innovations
broadened awareness
lasting relationships
sustainable development of activities
broad sharing of responsibility for different activities
o stronger ownership by stakeholders
o use of strengths of different partners
o sharing of knowledge and technology
o better balanced design of projects
Source: reference 3.
international collaboration
The World report on road traffic injury prevention
observes that although joint international road
safety efforts had taken place in the past, there had
been little coordinated planning between the
agencies involved on a large scale (I). No
international lead agency took responsibility for
ensuring that such coordinated planning was in
place. The report calls for a change in this situation
so that responsibility is clearly assigned, specific
roles are allocated to specific agencies, duplication is
avoided and a firm commitment is made to produce
and implement a global plan for road safety. The
United Nations General Assembly and World Health
Assembly have responded to this challenge and there
is now a growing United Nations Road Safety
Collaboration (Box 6.2).
BOX 6.2
United Nations Read Safety Collaboration
Since the adoption in 2004 of United Nations General Assembly resolution 58/289 on
Improving global road safety (4), WHO has been actively involved in coordinating road safety
within the United Nations system. The United Nations resolution invited WHO. in collaboration
with the United Nations regional commissions, to coordinate road safety efforts among the
United Nations agencies. Having accepted this mandate, WHO has facilitated the development
of a group of United Nations and other international road safety organizations - now referred to
as the “United Nations Road Safety Collaboration". As at February 2006, this group comprised
over 40 agencies, including 11 United Nations entities. The number and range of participating
organizations (governmental and nongovernmental organizations, donors, research agencies,
and the private sector) from the transport, health, and safety sectors attest to the broad support
for this collaborative effort. The group has articulated common objectives for its work, which
include addressing the main risk factors identified in the World report on road traffic injury
prevention (I).
Unit 6. MULTISECTORAL COLLABORATION • 93
There are other kinds of international
collaboration. For example, the Global Road Safely
Partnership is a global partnership between
business, civil society and governmental
organizations collaborating to improve road safety
conditions around the world. The Global Road
Safety Partnership is one of four Business Partners
for Development programmes initiated by the
World Bank. Business Partners for Development is
a project-based initiative that studies, supports and
promotes strategic examples of partnerships for the
development of communities around the world.
National multi-agency coordination
In many countries, responsibilities for road safety
are spread over different levels of government. In
most countries, road safely programmes have the
following arrangements:
o Ministries of public works and associated
agencies are responsible for provision and
maintenance of roads.
o Ministries of transport are responsible for traffic
laws and regulations, and for certification of
vehicles and drivers. In some countries, some of
these activities may be the responsibility of the
police department.
o Ministries of the interior are responsible for the
enactment of laws and their enforcement in
traffic, and the education of drivers and the other
road users.
o Ministries of education arc responsible for road
safety education.
o Ministries of health are responsible for
emergency medical services, hospital treatment
and rehabilitation of disabled people.
o Ministries of finance are responsible for the
allocation of sufficient resources to the relevant
agencies.
Though the government sector has a
responsibility for promoting and ensuring road
safety, it is essential that all the other players also be
involved as partners in this activity, in order to
increase the potential for better results. The
development of multisectoral institutional capacity,
both in the governmental and nongovernmental
spheres, is key to developing road safety, and can
only be delivered by a national political
commitment. To get all organizations and
individuals together, it is important to have
mechanisms that make it possible for this to happen.
A lead agency in government should be identified to
guide the national road safety effort. This is
discussed in Unit 7.
Activity
Task
Prepare a two-page summary on any form of
multisectoral collaboration on road traffic injury
prevention you know of in your country. In your
summary, indicate the aim, objectives, activities,
achievements and challenges faced.
Expected results
This exercise is intended to assist the trainees
with assessing the role of collaboration on road
traffic injury prevention. This should make them
appreciate both the benefits and challenges of
collaboration on road traffic injury prevention.
They can describe collaboration on research.
advocacy, an intervention and capacity building.
The trainees can also work in groups of three to
four persons so that they complement each
other’s knowledge.
Local community-based collaboration
People’s potential for improving their own situation
is enormous. The concept of community
involvement in health and development has been
promoted to counter strategies that fail to involve
people in creatively thinking and contributing to
finding solutions to problems dtat society faces. An
avenue for community participation can be through
the primary care programmes and training of
community health workers, nongovernmental
organizations, community-based organizations and
other grassroots groups.
Road safety projects need to be supported and
initialed by communities that live in different parts
of a nation. The government and municipal bodies
of a city or province can form an active association
with all stakeholders, including nongovernmental
organizations, researchers in universities, hospitals
and policy-makers, to work on programmes for the
94 « ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
prevention of road traffic injuries. An example of
an effort at securing the involvement of different
sectors of the local community in injury
prevention, including road traffic injuries, is the
Safe Community Movement (Box 6.3). Another
effort at collaboration that has mobilized members
of the community for advocacy is provided by
Mothers Against Drunk Drivers (Box 6.4).
BOX 6.3
Safe Community Movement
The Safe Community movement started in Sweden at the end of the 1980s. following the first
World Conference on Accident and Injury Prevention, held in Stockholm. Sweden, in 1989.
More than 500 delegates from 50 countries participated. A major premise of the meeting was
that community-level programmes for injury prevention are key to reducing injuries. At the
conclusion of the conference, a "Manifesto for Safe Communities” was issued, summarizing
important principles for injury control. The Safe Community movement has been developed by
the WHO Collaborating Centre on Community Safety Promotion at the Karolinska Institute in
Sweden. A safe community can be a municipality, a county, a city, or a district of a city, working
with safety promotion, and injury, violence and suicide prevention. The programme can cover
all age groups, genders and areas. The movement recognizes that it is the people who live and
work tn a community who have a good understanding of their community's needs, problems,
assets and capacities. The involvement and commitment of community members are important
in identifying and mobilizing resources for effective, comprehensive and coordinated
community-based action on injuries. To date. 83 communities have been designated as members
of the Safe Community Network.
Source, reference 5.
Mothers Against Drunk Drivers
The mission of Mothers Against Drunk Drivers is to stop drunk driving, support the victims of this
violent crime, and prevent under-age drinking. The organization was founded in May 1980. in
California, United Sates of America, by Candy Lightner after her 13 year old daughter was hit by a
drunk driver, who happened to be a repeat offender. Chapters were quickly started across the United
States in the early 1980s. Mothers Against Drunk Drivers is today one of the key road safety
advocacy groups in the United States, as well as in other countries such as Australia. Canada. New
Zealand, and the United Kingdom.
In the 1980s, Mothers Against Drunk Drivers popularized the concept of "designated drivers.”
Today, it is a household term, and bars and restaurants nationwide ask patrons to "designate a
driver”. Grassroots activism by Mothers Against Drunk Drivers has resulted in the passage of
a number of federal and state anti-drunk driving laws in the United States. The organization's most
well-known legislative campaign accomplishment came in 1984 when a United Slates federal law
required all states to increase the legal drinking age to 21 or else lose highway funding. In the mid1980s, Mothers Against Drunk Drivers launched an anti-impaired driving campaign and also
undertook a legislative agenda that focused on administrative licence revocation, open container
laws, a maximum blood alcohol content of 0.08%, a victim's bill of rights, compensation for victims
of crime, and several other measures.
Source' reference 6.
Unit 6. MULTISECTORAL COLLABORATION ° 95
Research collaboration
There are gaps in knowledge on road traffic injuries
that need to be addressed through research.
Research collaboration can take a number of forms,
for example:
° providing a mechanism of sharing knowledge
and experience among researchers and institutes
in a country;
° establishing a form of sharing information on
the funding of research projects by donors;
o bringing together researchers and institutions in
different countries in a networking arrangement.
Research collaboration can play an important
role in sharing knowledge, experience, expertise
and resources. It can reduce unnecessary
duplication of efforts. Two examples of research
collaboration in road traffic injuries are the Injury
Prevention Initiative for Africa (Box 6.5) and the
Road Traffic Injuries Research Network
(Box 6.6).
Key points
o The need for collaboration arises from the
diverse nature of the problem of road traffic
injuries. The problem has multiple determinants,
affects many people and sectors, and requires
action by different sectors.
o Multisectoral collaboration has benefits such as
increasing access to resources, sharing
responsibilities and strengthening ownership of
activities by stakeholders.
o Collaboration on road safety needs to be
organized around complementary issues at
international, regional, national and local
levels.
Definitions of key concepts
o Partnership: collaboration between two or more
persons and groups who agree to poo! talent and
resources, and share benefits. The partnership
may be formal or informal. In some cases, a
contract or agreement is signed.
o Network: an interconnected system of people
and groups collaborating on an issue. Like
partnership, the network may be formal or
informal, and may involve signing a contract or
an agreement.
Injury Prevention initiative for Africa
The Injury Prevention Initiative for Africa is a nongovernmental organization that was
established in 1997 to promote safety and injury research in Africa. It does this by:
o conducting research on epidemiology and control of all types of injuries;
o developing and conducting training programmes in injury epidemiology, surveillance,
prevention and acute care;
e promoting advocacy for the prevention and control of injury;
o facilitating the exchange of knowledge on injuries in Africa;
o providing liaison between African and international stakeholders in injury control.
The current membership of this Initiative comprises individuals from 14 African countries:
Egypt. Eritrea, Ethiopia, Ghana, Kenya, Mauritius. Mozambique, Nigeria, Rwanda. South
Africa. Uganda, United Republic of Tanzania. Zambia, and Zimbabwe. The Injury Prevention
Initiative for Africa is supported mainly by funding from WHO and the Canadian Network of
Surgeons International.
Source: reference 7.
96 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
BOX 6.6
Road Traffic Unjuries Research Network
The Road Traffic Injuries Research Network is a partnership of individuals and institutions government, academic, and nongovernmental - that collaborate to further research on the
impact, causes and strategies for the prevention of road traffic injuries in low-income and
middle-income countries. The Road Traffic Injuries Research Network evolved from work done
to address the “10/90 disequilibrium" (that is. of the estimated 100 billion US dollars spent on
health research annually, less than 10% is spent on addressing the health problems relevant to
90% of the world's population), and from the recognition that the neglect of research on road
traffic injuries in low-income and middle-income countries significantly contributes to this
disequilibrium. Collaborating partners meet to exchange ideas and develop a research agenda
on road traffic injuries. This network is contributing to developing capacity for road traffic
injury research in low-income and middle-income countries by providing mentorship.
information, research grants and guidance to researchers in these countries. The Road Traffic
Injuries Research Network is supported by the Global Forum for Health Research, the World
Bank, the George Institute for International Health, Australia, and WHO.
Source: reference 8.
Questions to think about
a)
b)
c)
Based on your work experience, describe a
collaboration project that you have participated
in. What were the main objectives of the
project? How many people were involved, and
what were their work and training
backgrounds? Were the project objectives
achieved? If they were, explain the role played
by each member of the project.
Discuss the roles of the different sectors
involved in road traffic injury prevention in
your country. How well do these sectors
collaborate in your country? What areas of
collaboration need to be improved? What
improvements do you recommend?
Identify and discuss the challenges that
professionals with an interest in international
collaboration on preventing road traffic injuries
face. How can these challenges be addressed?
2.
3.
4.
5.
6.
Mothers Against Drunk Drivers, MADD
history, Mothers Against Drunk Drivers
(http://www.madd.0rg/ab0utus/l 122. accessed
1 February 2006).
7.
Injury Prevention Initiative for Africa
(http://www.iccu.or.ug/partners/ipifa.php.
accessed I February 2006).
8.
Road Traffic Injuries Research Network
(http://www.rtirn.net/, accessed I February
2006).
References
1.
Peden M. et al. World report on road traffic
injury prevention. Geneva, World Health
Organization, 2004.
Resolution WHA57.10. Road safety and
health. In: Fifty-seventh World Health
Assembly, Geneva, 22 May 2004.
Silcock D. Strategies for action. In: FIA
Foundation for the Automobile and Society.
Sharing Responsibility for Safer Roads:
Conference Proceedings, 2003:56-61.
United Nations General Assembly resolution
A/58/289 on Improving global road safety (11
May 2004). New York, NY. United Nations
(http://www.who.int/violence_injury_
prevention/media/news/en/unga_58_289_en.p
df, accessed 1 February 2006).
Rahim Y. Safe community in different settings.
International Journal of Injury and Safety
Promotion. 2005, 12(2): 105-112.
Unit 6. MULTISECTORAL COLLABORATION • 97
Further reading
Costello A, Zumla A. Moving to research
partnerships in developing countries. British
Medical Journal. 2002. 321:827-829.
Drager N. McClintock E, Moffitt M. Negotiating
health development: a guide for practitioners.
Cambridge, MA, and Geneva, Conflict Manage
ment Group and World Health Organization, 2000.
ILLtLU JI H
98 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Notes
Unit 6. MULTISECTORAL COLLABORATION » 99
Trainee's evaluation of Unit 6: Multisectoral collaboration to prevent
road traffic injuries
This form is to be completed by ihe trainee at the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
1.
To what extent did you achieve the objectives set for this unit? (Please check once using “X” for each
objective)
Objectives
Completely
successful
Generally
successful
Completely
unsuccessful
Explain why there is a need for
multisectoral collaboration to prevent
road traffic injuries.
Describe
different
forms
of
collaboration for road traffic injury
prevention at international, national and
local levels.
Discuss the roles that different
institutions involved in road traffic
injury prevention can play.
Discuss how to effectively use
collaboration to strengthen efforts to
prevent road traffic injuries in his or her
own city, region and country.
2.
What is your overall rating of the content presented in this unit? (Please check one using “X")
Scale
Excellent
Better than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
b)
No
If yes. in what ways were they helpful? What improvements do you suggest?
100 • ROAD TRAFFIC INJURY PREVENTION- TRAINING MANUAL
c)
If no. what were the shortcomings? What suggestions do you have to make them helpful?
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you leant most from this unit?
8.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
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Unit 7. FORMULATING AND IMPLEMENTING ROAD SAFETY POLICY • 1 03
a
Overview
Policy formulation process
By the end of this unit, the trainee should able to:
Policy formulation and implementation is a
continuous process. This process is often presented
as taking place in phases or stages, in order to make
it easier to identify key elements. However, it
should be noted that this process is complex and it
does not necessarily move in a smooth manner
from one step to another.
For the sake of systematic presentation and
clarification of key issues, we present the process
of developing a national policy as taking place in
three phases (Figure 7.1). In Phase 1 the policy
development process is being initiated. In Phase 2
the policy document itself is being formulated.
o explain the importance of developing policies
for road traffic injury prevention;
FIGURE 7.1
o describe the process of developing a policy for
road traffic injury prevention;
The three phases of the policy development
process
ormulating and implementing policies is
necessary for improving road safety.
Policies will have no effect on road safety unless
they are implemented. This unit examines the
importance of road safety policy, and then
describes the basic steps and issues to consider in
formulating and implementing road safety
policy.
Objectives
o discuss the role of a national lead agency in
developing and implementing policies for
road traffic injury prevention.
PHASE 1 INITIATING THE POLICY DEVELOPMENT PROCESS
Step 1: Assess the situation
Step 2 Raise awareness
Importance of policy in
preventing road traffic injuries
The term policy can be interpreted in a variety of
ways. Here we consider a national policy on road
safety to be a written document that provides the
basis for action to be taken jointly by the
government and its nongovernmental partners (1).
A policy is necessary to (I, 2) :
o raise
awareness
and
create
mutual
understanding about a situation;
o articulate ethical and other principles that should
justify and guide action;
o generate a consensus vision on the actions to be
undertaken;
o provide a framework for action;
o define institutional responsibilities and
mechanisms of coordination;
o secure or raise political commitment;
o engage a variety of partners;
o identify measures which are likely to produce
good results;
o monitor progress and effectiveness of strategies.
Step 3: Identify leadership and foster political commitment
_.:
; z
Step 4: Involve stakeholders and create ownership
PHASE 2 FORMULATING THE POLICY
Slep 1. Define a framework
Step 2: Sei objectives and select interventions
I '
Step 3. Ensure that policy leads Io action
PHASE 3. SEEKING APPROVAL AND ENDORSEMENT
Step 1: Stakeholder approval
Slep 2: Government approval
Step 3: State endorsement
Source' reference 1
104 o ROAD TRAFFIC INJURY PREVENTION TRAINING MANUAL
Finally, in Phase 3 official approval and
endorsement of the policy is being sought. Each of
the three phases is composed of a number of steps.
Activity
Important points to note about the process
presented in Figure 7.1 are as follows:
Task
o In real life, a policy development process can be
much more chaotic than the best-case scenario
portrayed here. It may be necessary to jump
ahead and come back to a step that ideally
should have happened earlier on in the process.
o This process is influenced by social, economic
and political factors.
o Political will and commitment are necessary for
effective policy formulation and implementation.
o The process takes time, consultation, negotiation
and effort.
o Ensure that key stakeholders are involved in the
entire process.
o Consultation should be conducted with all
stakeholders in an open, fair and transparent
manner.
o Ensure that all the stakeholders approve and
endorse the policy document.
o The very act of developing a policy document
can bring about significant changes in attitudes
and perceptions that can go a long way towards
tackling a problem.
o Implementation of policy is essential once a
policy has been formulated.
e Implementation of road safety measures
requires coordinated action. Responsibilities at
different levels need to be clearly spelled out.
o Financial and human resources need to be
provided for implementation.
o Evaluating policy implementation is necessary.
Evaluation provides feedback on how well the
policy is working and can lead to improvement
of the policy itself.
Institutional framework
Road safety work is a complex process involving
different sectors. There is thus a need for a
functional and effective institutional framework for
the development and implementation of policies
and programmes to prevent road traffic injuries.
Is there a national road safety policy and action
plan in your country? If your answer is yes,
prepare a one-page summary of the aims, targets
and activities that have been implemented. What
are the strengths in the policy and plan? What are
the weaknesses in the policy and plan? If there is
no policy, what steps do you plan to take to
initiate the process of developing a national road
safety policy or action plan?
Expected results
This exercise is meant to assist trainees with
reviewing their national road safety policy and
action plan. If possible, the trainees should be
given this question in advance of the training
session so that they have time to gather the
relevant information. If this is not possible, allow
them answer based on their previous knowledge
and experience. This exercise is meant to get
trainees to think much more deeply about the
road safety policies and action plans in their
countries, and especially about whether or not
these policies and plans are being implemented.
The need for a lead agency
Though different institutional frameworks are
possible, there is a need to identify a lead agency
in government to guide the national road safety
effort. The lead agency should have authority and
responsibility to make decisions, control
resources and coordinate efforts by all sectors of
government - including those of health,
transport, education and the police. This agency
should have adequate finances to use for road
safety, and should be publicly accountable for its
actions.
Different models can be effective in road safety
and each country needs to create a lead agency
appropriate to its own circumstances. Specific
efforts should be taken by the agency to engage all
significant groups concerned with road safety. The
national road safety agency should be an
Unit 7. FORMULATING AND IMPLEMENTING ROAD SAFETY POLICY • 105
independent statutory organization attached to, or
functioning in parallel with the ministry dealing with
road transport, and it should be independent of the
road building agency. The road safety agency should
have a chairman of the rank of a minister or principal
secretary to the government of the country.
Awareness, communication and collaboration are
key to establishing and sustaining national road
safety' efforts. National efforts will be boosted if one
or more well-known political leaders can actively
champion the cause of road safety.
The specific tasks of a national lead agency
are to (I):
o manage, coordinate and commission all
activities regarding road safety in the country;
o advise all arms of the government on all matters
relating to road safety;
o formulate policy, set goals and elaborate
strategies for road safety in the country,
including the targeting of particular areas and
the setting of priorities;
o coordinate between different agencies of the
government, research and academic institutions.
and nongovernmental organizations;
o compile and analyse national statistics, and
ensure that comprehensive data exist for road
safety planning;
o set road safety research priorities and fund
projects in those priority areas;
o assemble and disseminate information and good
practice, including sharing research findings,
good practice models and experiences with
various agencies involved in road transport and
safety planning;
o establish and fund research and teaching
institutions and centres specifically for work on
road safety or transport and related issues;
o establish safety standards for roads, road
infrastructure and vehicles;
o monitor and evaluate the effectiveness of the
road safety strategies at the central and local
levels:
o encourage and enable local governments to set
up relevant institutional structures;
o organize regular national conferences on road
safety;
o procure sufficient finance for road safely work;
a coordinate the planning and implementation of
road safety work, taking into consideration the
interests of society, user groups, trade and
industry, and individuals, as well as
environmental aspects.
Sub-national and local institutions
While the national lead agency coordinates the
road safety effort for the entire country, it may
also be necessary to have sub-national
institutional structures to translate and implement
policy at the local level. Formal systems need to
be set up in each state or province, and in each city
to coordinate local efforts. Operational
intersectoral programmes can be designed and
implemented every year. These plans and
interventions take into account national priorities
as well as the local needs identified through the
involvement of local actors.
There could be a road safety agency in every
state or province. The form and structure of such
agencies would vary from country to country
because of wide differences in administrative and
financial structures at the sub-national level. The
provincial agency, which sets policy for road
safety in the province, can involve officials from
concerned departments, as well as representatives
of nongovernmental organizations and businesses
concerned with the road transport sector. The
actors involved could include departments of
roads, transport, police, education and health.
along with experts from academic and other
research institutions.
The provincial agency would take a leading
role in coordinating the road safety effort of all
relevant agencies and community groups within its
particular administrative area. These activities
should be consistent with the national road safety
plan, and the provincial agency should coordinate
activities across all relevant agencies in that
administrative area.
106 • ROAD TRAFFIC INJURY PREVENTION- TRAINING MANUAL
Key points
Questions to think about
o Policy formulation and implementation is a
continuous process.
a)
o This process is often presented as taking place in
phases or stages, to make it easier to identify key
elements, but the process is complex and does
not necessarily move in a smooth manner from
one step to another.
b)
o There is a need for a functional and effective
institutional framework for development and
implementation of policies and programmes to
prevent road traffic injuries.
o There is a need to identify a lead agency in
government to guide the national road safety
effort. The national lead agency coordinates the
road safety effort for the entire country'.
o It is necessary to have sub-national institutional
structures to translate and implement policy,
and coordinate activities across all relevant
agencies at the local level.
What is the relationship between policy and
legislation?
Is there a functional institutional framework for
road traffic injury prevention in the sub-national
administrative units in your country? What do
you identify as the strengths and weaknesses in
the existing framework? What practical steps do
you propose to take to address the weaknesses
you have identified?
References
1.
Schopper D. Lormand JD, Waxweiler R.
Developing policies to prevent injuries and
violence: guidelines for policy-makers and
planners. Geneva, World Health Organization.
2006.
2.
Foster M et al. Making policy. In: McClure R,
Stevenson M, McEvoy S. eds. The scientific
basis of injury prevention and control.
Definitions of key concepts
o Policy: a set of principles guiding decision
making. providing a framework against which
proposals or activities can be tested or measured
(1).
Melbourne,
267-282.
3.
IP
Communications,
2004:
North D. Institutions, institutional change and
economic performance. Cambridge. Cam
bridge University Press, 1990.
o Strategy: addresses the “how” of a national
policy by defining the main directions and
actions to achieve policy objectives.
Further reading
o Action plan: defines (more precisely than a
strategy) the specific activities, resources and
time frame needed to achieve policy objectives,
and provides guidance on how to implement,
monitor and evaluate activities.
health development: a guide for practitioners.
Cambridge,
MA, and
Geneva,
Conflict
Management Group and World Health Organi
zation, 2000.
o Institution: formal or informal system of rules,
structures and constraints that guide and shape
human interaction (3).
prevention. Geneva, World Health Organization.
2004.
Drager N, McClintock E, Moffitt M. Negotiating
Peden M et al. World report on mad traffic injury
Unit 7. FORMULATING AND IMPLEMENTING ROAD SAFETY
Notes
108 • ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
Trainee's evaluation of Unit 7: Formulating and implementing road
safety policy
This form is to be completed by the trainee al the end of this unit to assess the content and approach used.
This evaluation is helpful to the trainee, trainer and developer of this manual.
1.
To what extent did you achieve the objectives set for this unit? (Please check once using “X" for each
objective)
Objectives
Completely
successful
Generally
successful
Completely
unsuccessful
Explain the importance of developing
policies for road traffic injury
prevention.
|
Describe the process of developing a
policy for road traffic injury prevention.
Discuss the role of a national lead
agency in developing and implementing
policies for road traffic injury
prevention.
2.
What is your overall rating of the content presented in this unit? (Please check one using “X")
Scale
Excellent
Belter than expected
Satisfactory
Below average
Rating
3.
How do you rate the balance between theoretical and practical content in this unit? (Please check one
using “X”)
Scale
Good balance
Too theoretical
Too practical
Rating
4.
a) Did you find the activities presented in the unit helpful? (Please check one)
Yes
No
b)
If yes, in what ways were they helpful? What improvements do you suggest?
c)
If no, what were the shortcomings? What suggestions do you have to make them helpful?
Unit 7. FORMULATING AND IMPLEMENTING ROAD SAFETY POLICY • 109
5.
What did you like most about the unit?
6.
What did you like least about the unit?
7.
What did you learn most from this unit?
8.
Explain how your organization, community, city and country, and other interested parties will benefit
from your having read this unit.
9.
What do you think should be added to this unit?
10.
What do you think should be dropped from this unit?
Appendix
Trainer's evaluation of the manual
Trainer’s name:
Training location (district, town, city, country):
Trainer’s experience in road safety training (in years):
1. Please tick the appropriate box regarding the units that you have taught.
Unit taught
Number of trainees
Magnitude and impact of road traffic injuries
Risk factors for road traffic injuries
Importance of evidence as a foundation for prevention
Implementing specific interventions to prevent road
traffic injuries
Delivering post-crash care
Multisectoral collaboration
Formulating and implementing road safety policy
2.
Please assess each of the units you have taught as regards their relevance to the needs of trainees, using a
scale from 1 to 3, with 1 being the most relevant and 3 the least relevant. Please briefly explain why you
have given each score.
Please tick the appropriate box regarding the units that you have taught.
Unit taught
Magnitude and impact of road traffic injuries
Risk factors for road traffic injuries
Importance of evidence as a foundation for
prevention
Implementing specific interventions to prevent
road traffic injuries
Delivering post-crash care
Multisectoral collaboration
Formulating and implementing road safety policy
Score
Explanation
112 » ROAD TRAFFIC INJURY PREVENTION: TRAINING MANUAL
3.
Please help WHO lo improve the manual by answering the following questions, indicating any comments
or suggestions that you might have regarding the course. Please be as specific as you can.
a)
Are there any additional topics that you would suggest?
Tick as appropriate:
Yes
No
If you answered yes, please specify:
b)
Are there any topics or entire units that you would recommend to be merged?
Tick as appropriate:
Yes
No
If you answered yes, please specify:
c) Do you think any units need to be split into more than one?
Tick as appropriate:
Yes
No
If you answered yes, please specify which units.
d)
Are there any topics or entire units that you would recommend to be excluded?
Tick as appropriate: Yes
No
If you answered yes. please specify:
APPENDIX • 113
4.
a) Which of the suggested participatory learning activities did you use most? Please specify:
b) What additional participatory learning activities would you like to see included? Please specify:
c)
In what ways did you make the content relevant to the local context. Please specify, if possible by giving
examples:
5.
In general, which aspects of the units do you believe are most in need of improvement (overview,
objectives, content, learning activities, definitions of key concepts, questions to think about, references
and further reading). Please suggest specific improvements.
selected WHO publications
http://www.who.int/violence_injury_prevention/services/en/
http://www.who.int/violence_injury_prevention/services/en/
Developing
and violence:
(
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V'v/ Orjjnizjticn
http://www.who.int/violence_injury_prevention/policy/project/en/inciex.html
; shF
....
toad traffic collisions kill.about 1.2 million people around the world every year but they are largely
edas'a iiealth and development issue, perhaps because they are still viewed by many as
ieyond human cqntrol. Efforts to prevent road traffic injuries are hampered by a lack of human
caoacity. Policy-makers, researchers and practitioners need information on effective prevention
measures, and on how to develop, implement and evaluate such interventions. There is a need to train
lore specialists in road traffic injury prevention, in order to address the growing problem of road traffic
njuries at international and national levels.
r -tttt
■
y wnwerf^r1:'*1
manual provides guidance to professionals working on road traffic injury prevention. It is
lesigned for a multidisciplinary audience, including medical doctors, nurses, transport and road
■s, vehicle safety professionals, law enforcers, policy-makers, trainers, and social scientists,
contribute towards strengthening capacity to implement measures to prevent road traffic
n different settings around the world. The manual covers the fundamental aspects of road
raffle injury prevention:
iagnitude arid impactof road traffic injuries;
risk factors for road traffic injuries;
importance of evidence as a foundation for prevention;
implementing specific interventions to prevent road traffic injuries;
“• -
delivering post-crash care;
•
multisectoral collaboration;
■
formulating and implementing road safety policy.
ISBN 92 4 1546751
9 789241
546751
- Media
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