Lives saved by laws and regulations that resulted from the Bloomberg road safety program

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

A new alcohol-related traffic law, a further reduction in traffic fatalities? Analyzing the case of Turkey

BACKGROUND

In June 2013, an alcohol-related traffic law took effect in Turkey. The law 6487 introduced administrative fines for not respecting blood alcohol concentration limits, health warning messages on alcohol containers (bottles, cans), and prohibited the sale of alcohol beverages in retail facilities between 10 p.m. and 6 a.m.. This article examines how this law is associated with traffic fatality variation.

METHODS

Data from the Turkish Statistical Institute for the 2008-2019 period were analyzed. Outcomes were traffic fatality rates per 100,000 population and 10,000 motor vehicles. Exposure variable was the presence of law 6487. Alcohol, tobacco, and related beverages' household expenditure, unemployment rate, number of health professionals, number of crashes, and lags of the outcomes represented control variables. A time-series cross-regional fixed effect model was applied.

RESULTS

Empirical estimates suggest that the law 6487 was associated with a reduction of 15% (Incidence Rate Ratio (IRR) 0.85, 95% Confidence Interval (CI): 082, 0.94) in the traffic fatality per population rate and with a reduction of 14% (IRR: 0.86 (95% CI: 0.78, 0.92) in the traffic fatality per motor-vehicle rate. After 6 years of its implementation, this intervention was associated with an absolute reduction of 1519 (95% reduction interval: 1177, 1810) traffic fatalities.

CONCLUSIONS

Our research emphasizes that legislation with direct and indirect measures targeting driving under the influence of alcohol (DUIA) may be related to traffic fatalities reduction.

PRACTICAL APPLICATIONS

This finding has important implications for policy and future research in contexts in which alcohol consumption is low such is in Turkey. Future research should seek to identify mechanisms that explain how laws are ultimately associated with DUIA variation.

[Assessment of road safety intervention implementation in Benin in 2019]

OBJECTIVE

The study aims to assess the level of implementation of road safety interventions in Benin.

METHOD

The research is based on an evaluative study of road safety aimed to analyze the implementation and logic of road safety interventions, conducted in Benin in 2019. It combined a review of the gray literature and a qualitative component. The data were collected through documents and interviews in structures involved in road safety management.

RESULTS

Road safety was a national priority with one lead institution and several structures involved. There was a lack of consensus among stakeholders, insufficient framework documents, resources, legislative texts, and study data. Few roads were in good condition and very few allowed the separation of two-wheeled vehicles. The vehicle fleet was outdated. Various activities were carried out to raise awareness, to educate the population and to enforce the texts but they were insufficient and poorly coordinated. Reference hospitals had the minimum service to deal with trauma cases. The interventions had not yet resulted in a reduction in the number of injuries and fatalities by accidents, which was increasing.

CONCLUSION

Benin has made great efforts in the area of road safety. However, there are still some shortcomings to take into account.

Studies of the effectiveness of transport sector interventions in low- and middle-income countries: An evidence and gap map

BACKGROUND

There are great disparities in the quantity and quality of infrastructure. European countries such as Denmark, Germany, Switzerland, and the UK have close to 200 km of road per 100 km², and the Netherlands over 300 km per 100 km². By contrast, Kenya and Indonesia have <30, Laos and Morocco <20, Tanzania and Bolivia <10, and Mauritania only 1 km per 100 km². As these figures show, there is a significant backlog of transport infrastructure investment in both rural and urban areas, especially in sub-Saharan Africa. This situation is often exacerbated by weak governance and an inadequate regulatory framework with poor enforcement which lead to high costs and defective construction.The wellbeing of many poor people is constrained by lack of transport, which is called "transport poverty". Lucas et al. suggest that up to 90% of the world's population are transport poor when defined as meeting at least one of the following criteria: (1) lack of available suitable transport, (2) lack of transport to necessary destinations, (3) cost of necessary transport puts household below the income poverty line, (4) excessive travel time, or (5) unsafe or unhealthy travel conditions.

OBJECTIVES

The aim of this evidence and gap map (EGM) is to identify, map, and describe existing evidence from studies reporting the quantitative effects of transport sector interventions related to all means of transport (roads, rail, trams and monorail, ports, shipping, and inland waterways, and air transport).

METHODS

The intervention framework of this EGM reframes Berg et al's three categories (infrastructure, prices, and regulations) broadly as infrastructure, incentives, and institutions as subcategories for each intervention category which are each mode of transport (road, rail trams and monorail, ports, shipping, and inlands waterways, and air transport). This EGM identifies the area where intervention studies have been conducted as well as the current gaps in the evidence base.This EGM includes ongoing and completed impact evaluations and systematic reviews (SRs) of the effectiveness of transport sector interventions. This is a map of effectiveness studies (impact evaluations). The impact evaluations include experimental designs, nonexperimental designs, and regression designs. We have not included the before versus after studies and qualitative studies in this map. The search strategies included both academic and grey literature search on organisational websites, bibliographic searches and hand search of journals.An EGM is a table or matrix which provides a visual presentation of the evidence in a particular sector or a subsector. The map is presented as a matrix in which rows are intervention categories (e.g., roads) and subcategories (e.g., infrastructure) and the column outcome domains (e.g., environment) and subcategories as (e.g., air quality). Each cell contains studies of the corresponding intervention for the relevant outcome, with links to the available studies. Included studies were coded according to the intervention and outcomes assessed and additional filters as region, population, and study design. Critical appraisal of included SR was done using A Measurement Tool to Assess Systematic Reviews (AMSTAR -2) rating scale.

SELECTION CRITERIA

The search included both academic and grey literature available online. We included impact evaluations and SRs that assessed the effectiveness of transport sector interventions in low- and middle-income countries.

RESULTS

This EGM on the transport sector includes 466 studies from low- and middle-income countries, of which 34 are SRs and 432 impact evaluations. There are many studies of the effects of roads intervention in all three subcategories-infrastructure, incentives, and institutions, with the most studies in the infrastructure subcategories. There are no or fewer studies on the interventions category ports, shipping, and waterways and for civil aviation (Air Transport).In the outcomes, the evidence is most concentrated on transport infrastructure, services, and use, with the greatest concentration of evidence on transport time and cost (193 studies) and transport modality (160 studies). There is also a concentration of evidence on economic development and health and education outcomes. There are 139 studies on economic development, 90 studies on household income and poverty, and 101 studies on health outcomes.The major gaps in evidence are from all sectors except roads in the intervention. And there is a lack of evidence on outcome categories such as cultural heritage and cultural diversity and very little evidence on displacement (three studies), noise pollution (four studies), and transport equity (2). There is a moderate amount of evidence on infrastructure quantity (32 studies), location, land use and prices (49 studies), market access (29 studies), access to education facilities (23 studies), air quality (50 studies), and cost analysis including ex post CBA (21 studies).The evidence is mostly from East Asia and the Pacific Region (223 studies (40%), then the evidence is from the sub-Saharan Africa (108 studies), South Asia (96 studies), Latin America & Caribbean (79 studies). The least evidence is from Middle East & North Africa (30 studies) and Europe & Central Asia (20 studies). The most used study design is other regression design in all regions, with largest number from East Asia and Pacific (274). There is total 33 completed SRs identified and one ongoing, around 85% of the SR are rated low confidence, and 12% rated as medium confidence. Only one review was rated as high confidence. This EGM contains the available evidence in English.

CONCLUSION

This map shows the available evidence and gaps on the effectiveness of transport sector intervention in low- and middle-income countries. The evidence is highly concentrated on the outcome of transport infrastructure (especially roads), service, and use (351 studies). It is also concentrated in a specific region-East Asia and Pacific (223 studies)-and more urban populations (261 studies). Sectors with great development potential, such as waterways, are under-examined reflecting also under-investment.The available evidence can guide the policymakers, and government-related to transport sector intervention and its effects on many outcomes across sectors. There is a need to conduct experimental studies and quality SRs in this area. Environment, gender equity, culture, and education in low- and middle-income countries are under-researched areas in the transport sector.

Lives Saved in Low- and Middle-Income Countries by Road Safety Initiatives Funded by Bloomberg Philanthropies and Implemented by Their Partners between 2007-2018

Over the past 12 years, Bloomberg Philanthropies (BP) and its partner organisations have implemented a global road safety program in low- and middle-income countries. The program was implemented to address the historically increasing number of road fatalities and the inadequate funding to reduce them. This study evaluates the performance of the program by estimating lives saved from road safety interventions implemented during the program period (2007–2018) through to 2030. We estimated that 311,758 lives will have been saved by 2030, with 97,148 lives saved up until 2018 when the evaluation was conducted and a further 214,608 lives projected to be saved if these changes are sustained until 2030. Legislative changes alone accounted for 75% of lives saved. Concurrent activities related to reducing drink driving, implementing legislative changes, and social marketing campaigns run in conjunction with police enforcement and other road safety activities accounted for 57% of the total estimated lives saved. Saving 311,758 lives with funding of USD $259 million indicates a cost-effectiveness ratio of USD $831 per life saved. The potential health gains achieved through the number of lives saved from the road safety initiatives funded by Bloomberg Philanthropies represent a considerable return on investment. This study demonstrates the extent to which successful, cost-effective road safety initiatives can reduce road fatalities in low- and middle-income countries.

Helmet Wearing Saves the Cost of Motorcycle Head Injuries: A Case Study from Karachi, Pakistan

Purpose

To estimate the difference in healthcare cost of head injuries among motorcycle helmet users and non-users.

Methods

Motorcycle crash victims with head injuries that were brought to a public, tertiary care emergency room in Karachi were studied through a descriptive cross-sectional design. A standard questionnaire was used to collect data on demographics, injury pattern, helmeting practice, length of hospital stay, out-of-pocket payments (OOPs), and healthcare service utilization at the facility to estimate total healthcare and other costs applying micro-costing methods during the hospitalization period.

Results

A total of 323 motorcyclists involved in crash were brought to a public tertiary care ER, 112 patients had head injuries and were enrolled in the study. The helmeted motorcyclists had a significantly lower median total healthcare cost of PKR 10,796 ($69) [IQR 9851 ($63)–PKR 12,581 ($80)] compared to higher cost of PKR 12,113 ($77) [IQR 10,431 ($66)−50,545 ($322)] (p value = 0.046) in non-helmeted. Helmet users expended significantly less cost on laboratory tests, PKR 365 ($2) [IQR 365 ($2)–548 ($3)] compared to PKR 3650 ($23) [IQR 365 ($2)–5840 ($37)] (p value =0.027) among non-users. Furthermore, cost of radiological investigations was also low among helmeted patients compared to non-helmeted ones, median PKR 4096 ($26) [IQR 3166 ($20)–5678 ($36)] vs 4750 ($30) [3166 ($20)−11,358 ($72)] (p value =0.049). The out-of-pocket payments (OOPs) for healthcare services were lower among helmet users as compared to non-users, with cost of PKR 17,750 ($113) [IQR 16,650 ($106)–18,000 ($115)] vs PKR 19,800 ($126) [IQR 12,300 ($78)–30,900 ($197)] (p value =0.03), respectively.

Conclusion

The result of this study demonstrates that helmet use among motorcyclists significantly reduced healthcare costs and healthcare resource utilizations during hospitalization for head injuries in Pakistan. Thus, it is important to implement strict helmet wearing laws to decrease head injuries and the cost burden on the healthcare facility and patients.

Fifty Years of Accident Analysis & Prevention: A Bibliometric and Scientometric Overview

Accident Analysis & Prevention (AA&P) is a leading academic journal established in 1969 that serves as an important scientific communication platform for road safety studies. To celebrate its 50^th anniversary of publishing outstanding and insightful studies, a multi-dimensional statistical and visualized analysis of the AA&P publications between 1969 and 2018 was performed using the Web of Science (WoS) Core Collection database, bibliometrics and mapping-knowledge-domain (MKD) analytical methods, and scientometric tools. It was shown that the annual number of AA&P's publications has grown exponentially and that over the course of its development, AA&P has been a leader in the field of road safety, both in terms of innovation and dissemination. By determining its key source countries and organizations, core authors, highly co-cited published documents, and high burst-strength publications, we showed that AA&P's areas of focus include the "effects of hazard and risk perception on driving behavior", "crash frequency modeling analysis", "intentional driving violations and aberrant driving behavior", "epidemiology, assessment and prevention of road traffic injuries", and "crash-injury severity modeling analysis". Furthermore, the key burst papers that have played an important role in advancing research and guiding AA&P in new directions - particularly those in the fields of crash frequency and crash-injury severity modeling analyses were identified. Finally, a modified Haddon matrix in the era of intelligent, connected and autonomous transportation systems is proposed to provide new insights into the emerging generation of road safety studies.

Effectiveness of implementing the criminal administrative punishment law of drunk driving in China: An interrupted time series analysis, 2004-2017

In 2011, a more severe drunk driving law was implemented in China, which criminalized driving under the influence of alcohol for the first time and increased penalties for drunk driving. The present study aimed to assess effectiveness of the drunk driving law in China in reducing traffic crashes, injuries, and mortality. Data used in this study was obtained from the Traffic Management Bureau of the Ministry of Public Security of the People's Republic of China. An interrupted time series analysis was conducted to analyze annual data from 2004 to 2017, including the number of road traffic crashes, deaths, and injuries caused by drunk driving in China. The average annual incidences of crashes, mortality, and injuries have decreased after the promulgation of drunk driving law in 2011. In the post-intervention period, the increased slope for crashes, mortality and injury rates were, respectively, -0.140 to -0.006, -0.052 to -0.005 and -0.150 to -0.008, indicating a weaker downward trend of dependent variables. The more stringent drunk driving law is not as effective as expected. Drunk driving is still a severe traffic safety problem to be addressed in China. Both legislation and other prevention programs should be adopted to reduce road traffic injuries caused by drunk driving in China.

The effects of Chile's 2005 traffic law reform and in-country socioeconomic differences on road traffic deaths among children aged 0-14 years: A 12-year interrupted time series analysis

OBJECTIVES

This study assessed the effect of Chile's 2005 traffic law reform (TLR) on the rates of road traffic deaths (RTD) in children aged 0-14 years, adjusting for socioeconomic differences among the regions of the country.

METHODS

Free-access sources of official and national information provided the data for every year of the study period (2002-2013) and for each of the country's 13 upper administrative divisions with respect to RTD in child pedestrians and RTD in child passengers (dependent variables), and the following control variables: the number of road traffic tickets processed, investment in road infrastructure, poverty, income inequality, insufficient education, unemployment, population aged 0-14 years, and prevalence of alcohol consumption in the general population. Interrupted time series analyses (level and slope change impact model), using generalized estimating equation methods, were conducted to assess the impact of the TLR (independent variable) on the dependents variables.

RESULTS

There was a significant interaction between time and Chile's 2005 TLR for a reduction in child pedestrians (incidence rate ratio [IRR] 0.87, 95% confidence interval [CI] 0.79-0.96) and passengers RTD (IRR for interaction 0.80, 95% CI 0.67-0.96) trends. In addition, in child pedestrians, RTD rates were affected by poverty (IRR 1.04, 95% CI 1.02-1.05), income inequality (IRR 1.02, 95% CI 1.00-1.04), and unemployment (IRR 0.94, 95% CI 0.90-0.98), whereas in the case of child passengers, poverty (IRR 1.05, 95% CI 1.01-1.08) and income inequality (IRR 0.93, 95% CI 0.91-0.95) were significant.

CONCLUSIONS

Large-scale legislative actions can be effective road safety measures if they are aimed at promoting behavioral change in developing countries, improving the safety of children on the road. Additionally, regional socioeconomic differences are associated with higher RTD rates in this population, making this an argument in favor of road safety policies that consider these inequalities. The number of road traffic tickets processed and the investment in road infrastructure were not significant.

How did a lower drink-drive limit affect bar trade and drinking practices? A qualitative study of how alcohol retailers experienced a change in policy

Introduction and Aims

Reducing the legal drink‐drive limit from 0.08% to 0.05% blood alcohol concentration (BAC) can reduce road traffic accidents and deaths if properly enforced. Reduced limits may be opposed by alcohol retail and manufacturing industries on the basis of commercial impact. Our aim was to qualitatively explore how a reduction in the drink‐drive limit from 0.08% to 0.05% BAC in Scotland, was experienced by bar owners or managers, including any resultant changes in customer drinking or business practice. This is the first study of this type.

Design and Methods

Semi‐structured interviews were conducted with 16 owners and managers of on‐trade premises in Scotland in 2018, approximately three years after the drink‐drive limit was reduced. Data were analysed using thematic analysis.

Results

Most participants reported no long‐term financial impact on their business, but a few, mainly from rural areas, reported some reduction in alcohol sales. Observed drinking changes included fewer people drinking after work or leaving premises earlier on weekdays. Adaptations to businesses included improving the range of no/low‐alcohol drinks and food offered. Changes such as these were seen as key to minimising economic impact.

Discussion and Conclusions

Opposition to legislative measures that impact on commercial interests is often strong and receives significant public attention. This study found that Scottish businesses that adapted to the drink‐drive limit change reported little long‐term economic impact. These findings are of international relevance as potential BAC limit reductions in several other jurisdictions remain the subject of debate, including regarding the impact on business.

Crash patterns in two Chinese secondary cities, with comparisons to crash patterns in the United States

Objective: Evaluations of drink-driving crash interventions and crash burden in middle-income countries often rely on assumptions supported by data from the United States. We described crashes using pooled survey data across 2 Chinese agricultural cities in the 600,000 population range and then assessed comparability of selected crash characteristics to those in the United States.Methods: We conducted household interviews on drinking and related harms with representative samples of 1,500 people aged 18 and over in both Jiangshan and Lanxi, China. Near the end of the survey, 2,962 people responded to questions about motor vehicle crashes during the past year. We report survey data weighted to match the population demographically.Results: Across the 2 cities, 28% of adults were licensed drivers and 24% drove a motorized vehicle. Fifty-three respondents (unweighted) reported that they personally were involved in at least one crash in the past year. Among these, 32% (weighted) were driving a car, truck, or bus; 7.5% were driving a motorcycle; 9.5% were pedalcyclists; 17% were pedestrians; and 34% were passengers. Of the crashes, 42% involved just one motorized vehicle. Most crashes (62%) occurred in broad daylight, followed by at dawn or dusk (19%) and at night (19%). Only 4% were single-vehicle nighttime crashes. Someone was injured or killed in 22% of crashes. Respondents thought it likely that at least one driver was drinking alcohol in 21% of the crashes and thought it unlikely in 51%; the remaining 28% were unsure whether anyone was drinking or refused this question. Alcohol involvement was similar in injury and no-injury crashes. Respondents thought a driver had been drinking in 24% of daytime crashes, 34% of crashes at dawn or dusk, and 36% of nighttime crashes. All 3 crashes involving an alcohol-involved pedestrian or pedalcyclist also included an alcohol-involved driver. Respondents said that 40% of the crashes were reported to the police and 40% were not reported; the remaining 20% of respondents did not know whether anyone reported their crash. Among crashes where reporting status was known, all crashes with injuries were reported.Conclusions: Compared to published data, crash rates are similar among licensed drivers in the United States and these Chinese cities. The percentage of crashes that involved injury did not differ significantly between the 2 countries. Injury crashes were well reported in both. Crashes involving property damage only were significantly less likely to be reported to the police in the Chinese cities. Alcohol involvement rates in crashes were similar. Although our crash sample was small, some crash parameters appear to be transferable between these 2 countries.

Drink driving and speeding in Sao Paulo, Brazil: empirical cross-sectional study (2015-2018)

OBJECTIVES

To evaluate the prevalence of drink driving and speeding during 2015-2018 in Sao Paulo, Brazil.

DESIGN

Cross-sectional observational study.

SETTING

Roads representing the five main regions of the city of Sao Paulo in Brazil, one of the world's largest urban areas.

PARTICIPANTS

Drivers (N=10 294) stopped at routine roadside breath testing checkpoints and those driving in selected roads for speeding measurement (N=414 664).

PRIMARY AND SECONDARY OUTCOME MEASURES

Microwave radar guns were used to measure the speed of vehicles, while the prevalence of drivers under the influence of alcohol was observed in police checkpoints. Data were collected during three consecutive years (2016-2018) following a baseline study established in 2015 using a city-level representative sample of observational data representing all days of the week.

RESULTS

Alcohol-related fatalities kept at a constantly high percentage, with 39% of road traffic deaths involving alcohol in 2016. Drivers testing above the legal breath alcohol concentration limit showed a decreasing trend, from 4.1% (95% CI 2.9% to 5.5%) at baseline to 0.6% (95% CI 0.2% to 1.2%) in the end of 2018 (p<0.001); however, more than half of drivers refused breath tests at checkpoints despite steep legal penalties. The prevalence of speeding among all vehicles decreased from 8.1% (95% CI 7.9% to 8.2%) to 4.9% (95% CI 4.7% to 5.1%) by the end of 2016 (p<0.001), but then increased again to 13.5% (95% CI 13.2% to 13.9%) at the end of the study period (p<0.001).

CONCLUSIONS

Drink driving rates have reduced, likely due to an increase in drivers refusing breath alcohol tests, while speeding rates have increased significantly by the end of the study period, particularly among motorcycles. Future strategies aiming at reducing road traffic injuries in the major Brazilian city should tailor drink driving and speeding enforcement based on the new evidence provided here.