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

Knowledge of Healthcare Workers Regarding Road Traffic Child Safety in South Bačka District, Serbia

Introduction

Healthcare workers (HCW) can have an important role in educating parents about child road safety, but research on the topic shows that they usually do not have adequate knowledge. Thus, the aim of our study was to analyze their knowledge in the field of child road safety.

Methods

The cross-sectional study was conducted among HCW from South Bačka district, Serbia, using a specially created questionnaire for assessing knowledge on road traffic injuries in children.

Results

The research involved the participation of 317 healthcare workers (86 physicians and 231 nurses). Healthcare workers from primary healthcare made up almost 70% of all respondents, followed by those from tertiary (21.8%) and secondary (11.3%) level institutions. The average percentage of correct answers on the knowledge test was 74.3% (mean=22.3, SD=4.0). Out of all respondents, HCWs employed in the paediatrics department had a significantly higher percentage of correct answers at 77.7% (mean=23.3, SD=3.4) compared to other health workers at 73% (mean=21.9, SD=4.1) (p=0.002). Association analysis demonstrated that HCW employed at paediatric departments on average scored 1.37 (95% CI: 0.40-2.33, p=0.006) points higher in comparison with other HCW.

Conclusion

This research demonstrated an unsatisfactory level of knowledge on child road safety by HCW, and the variability across different question domains, which underlines the need for continuous educations in order to improve their knowledge. Our results may serve in planning additional public health measures and can provide a reference for future studies.

Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study

BACKGROUND

Following the change of government in August 2021, the social and economic landscape of Afghanistan deteriorated into an economic and humanitarian crisis. Afghans continue to struggle to access basic healthcare services, making Universal Health Coverage (UHC) in the country a major challenge. The aim of this study was to perform a qualitative investigation into the main access to care challenges in Afghanistan and whether these challenges have been influenced by the recent socio-political developments, by examining the perspectives of health professionals and hospital directors working in the country.

METHODS

Health professionals working in facilities run by an international non-government organisation, which has maintained continuous operations since 1999 and has become a key health reference point for the population, alongside the public health system, and hospital directors working in government hospitals were recruited to participate in an in-depth qualitative study using semi-structured interviews.

RESULTS

A total of 43 participants from ten provinces were interviewed in this study. Four issues were identified as critical barriers to achieving UHC in Afghanistan: (1) the lack of quality human resources; (2) the suboptimal management of chronic diseases and trauma; (3) the inaccessibility of necessary health services due to financial hardship; (4) the unequal accessibility of care for different demographic groups.

CONCLUSIONS

Health professionals and hospital directors shed light on weaknesses in the Afghan health system highlighting chronic issues and issues that have deteriorated as a result of the 2021 socio-political changes. In order to improve access to care, future healthcare system reforms should consider the perspectives of Afghan professionals working in the country, who are in close contact with Afghan patients and communities.

Police and hospital data linkage for traffic injury surveillance: A systematic review

This systematic review examines studies of traffic injury that involved linkage of police crash data and hospital data and were published from 1994 to 2023 worldwide in English. Inclusion and exclusion criteria were the basis for selecting papers from PubMed, Web of Science, and Scopus, and for identifying additional relevant papers using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and supplementary snowballing (n = 60). The selected papers were reviewed in terms of research objectives, data items and sample size included, temporal and spatial coverage, linkage methods and software tools, as well as linkage rates and most significant findings. Many studies found that the number of clinically significant road injury cases was much higher according to hospital data than crash data. Under-estimation of cases in crash data differs by road user type, pedestrian cases commonly being highly under-counted. A limited number of the papers were from low- and middle-income countries. The papers reviewed lack consistency in what was reported and how, which limited comparability.

Recommendations for effective collaboration and capacity building in epidemiological studies on the effect of alcohol and drug use on traffic safety in low- and middle-income countries

OBJECTIVE

Alcohol or drug impairment is a major risk factor for road traffic crashes, and studies on this issue are essential to provide evidence-based data for policymakers. In low- and middle-income countries (LMICs), such studies are often conducted in partnership with one or more organizations in high-income countries (HICs). The aim of this article is to provide recommendations for improving project planning and decision-making processes in epidemiological studies on alcohol, drug and traffic safety in LMICs involving HICs.

METHODS

We searched Pubmed, Google Scholar, and Google Search for articles and reports in English about lessons learned when conducting collaborative research in LMIC as well as papers presenting recommendations for effective research collaboration with partners in LMICs.

RESULTS

Based on the search results, we selected 200 papers for full text examination. Few were related to studies on the effect of alcohol or drug use on road traffic safety. However, several conclusions and recommendations from other studies were found to be relevant. We combined the findings with our own experience in a narrative review. We also present a checklist for risk and quality assessment.

CONCLUSIONS

Many papers presented similar recommendations, which included the importance of addressing local needs, ensuring adequate resources, local project ownership and leadership, establishing strong partnerships among all involved stakeholders, promoting shared decision-making and planning, and implementing strategies to translate research findings into policy, practice, and publications. It is also important to avoid HIC bias, which prioritizes the interests or perspectives of HICs over those of LMICs.

Exploring improvisations in road safety in a low-income setting

Road collision types repeat themselves, especially in low- and middle-income countries (LMICs), where countermeasures are often improvised and implemented with little planning. At the Shahbag intersection in Dhaka, Bangladesh, speed bumps were quickly constructed at the exit of the intersection as an improvised road safety measure following the occurrence of a fatal collision, which eventually contributed to another collision between a truck and a car. The events influencing the improvisation decision, and that action's consequences, have been analysed using the Impromap methodology, a variation of the Accimap approach that focusses specifically on improvisation. The applicability of the Impromap as a systems-based approach to the road safety domain is assessed using the predictions described in Rasmussen's risk management framework, and corresponding countermeasures are proposed. The analysis shows that improvisation in the road safety domain is undesirable irrespective of the economic setting as it is likely to eventually contribute to secondary collisions.Practitioner summary: In this paper, the events influencing the improvisation decision following a road crash, and that action's consequences, have been analysed using the Impromap methodology. The applicability of Impromap as a systems-based approach in road safety domain is assessed using the Rasmussen's risk management framework-based predictions, and corresponding countermeasures are proposed.

Towards safer streets: A framework for unveiling pedestrians' perceived road safety using street view imagery

Road safety has become a global concern but its impact in low- and middle-income countries is widespread mainly due to lack of appropriate crash database system and under-reporting. In this context, the primary objective of this paper is to provide a scalable framework for unveiling pedestrians' perceived road safety that can also be applied in regions where accessible crash data are limited or near-crashes are left unreported. In the first step of our methodology, a deep learning architecture-based semantic segmentation model (HRNet+OCR) is trained using labeled Google Street View (GSV) images from specific study areas in Dhaka, Bangladesh, which facilitates the identification of both man-made components (such as roads, sidewalks, buildings, and vehicles) and natural elements (including trees and sky). The developed model showed excellent performance in identifying different features in an image by achieving high precision (0.95), recall (0.97), F1-score (0.96), and intersection over union (IoU) (91.86). Secondly, a group of trained raters scored the perceived road safety on an ordinal scale from 0 to 10 (extremely unsafe to extremely safe to walk in terms of road crashes) by assessing the GSV images. Then, several regression models have been used on features extracted from GSV images, and socio-demographic factors (i.e., population density, and relative wealth index) to estimate the perceived road safety, and random forest regression model was found to perform the best. Further, Shapley Additive Explanations (SHAP), a model-agnostic technique has been used for examining feature importance by computing the contribution of each feature to the random forest regression model output. The results show that sidewalk, road, population density, wall, and relative wealth index have higher impact on determining the perceived road safety rating. Additionally, the results of t-tests between the average perceived road safety scores for crash-prone and non crash-prone areas revealed the existence of significant differences. This study also provides perceived road safety rating map on a neighborhood scale, which can be a useful visualization tool for policy-makers and practitioners to identify the road safety deficiencies at specific locations, and formulate appropriate and strategic countermeasures to improve pedestrians' road safety.

Prevention of "bygone futures" due to road traffic injuries in children

Road traffic injuries remain one of the common and leading causes of death among children and adolescents till the age of 19 years. Road safety is important for children since their physical activity, active travel, independence and development are largely affected by it. Solutions for road safety with benefits for people as well as an economy exist which should be implemented effectively and efficiently. These solutions which combine engineering, legislation and behavioural interventions should be implemented in an integrated Safe Systems Approach. The future of the children must be safeguarded from these injuries and every effort towards it being converted into "bygone figures" must be done diligently and honestly. The various risk factors and interventions possibly explained in this review article shall help in better understanding of the causes and possible guidelines at a policy level to prevent road traffic injuries in children.

Burden of Childhood Injuries in India and Possible Public Health Interventions: A Systematic Review

Childhood injuries are a major public health challenge in India and globally. This systematic review was conducted to understand the burden and spectrum of childhood injuries, with a focus on unintentional injuries, among children 5-14 years of age and to suggest approaches to prevention that can be adopted in the Indian context. This systematic review was conducted with the standard approach and use of keywords. A total of 33 studies which were found to be relevant were analyzed. Road traffic accidents (RTAs) contribute to nearly 85% of all unintentional injuries and related deaths and 90% of disability-adjusted life years (DALYs) lost in developing countries. Poor traffic regulation, heavy traffic load, and poor skill of identifying the dangerous road crossing sites make the children's age group vulnerable and prone to RTA. Children with poor skill of identification and response to dangerous road crossing sites, along with heavy unregulated traffic were found to be the major reasons for such accidents and make this age group more vulnerable. Public health-based prevention approaches need to be based upon legislation, regulation, and enforcement, as well as environmental modification, education and skill development, emergency medical care using levels of prevention, and principles of targeted prevention to effectively address child health challenges. Addressing child injuries should be a key component of all endeavors aimed at enhancing child mortality and morbidity rates, as well as the overall welfare of children, both at the national and global levels. It is imperative to prioritize policies focused on preventing unintentional injuries across all age groups, with particular attention to children.

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

The influence of middle-aged male driver profile on driving performance and the effects of three perceptual countermeasures: A simulator study

The human-environment-vehicle triad and how it relates to crashes has long been a topic of discussion, in which the human factor is consistently seen as the leading cause. Recently, more sophisticated approaches to Road Safety have advocated for a road-driver interaction view, in which human characteristics influence road perception and road environment affects driver behavior. This study focuses on road-driver interaction by using a driving simulator. The objective is to investigate how the driver profile influences driving performance and the effects of three countermeasures (peripheral transverse lines before and after the beginning of the curves and roadside poles in the curves). Fifty-six middle-aged male participants drove a non-challenging rural highway simulated scenario based on a real road where many single-vehicle crashes occurred. The drivers' profiles were assessed through their behavioral history measured by a validated version of the Driver Behavior Questionnaire (DBQ) comprising three dimensions: Errors (E), Ordinary Violations (OV), and Aggressive Violations (AV). The relationship between speed and trajectory measures and drivers' profiles was investigated using random-parameter models with heterogeneity in the means. The models' results showed that the DBQ subscale scores in OV explained a considerable part of the heterogeneity found in drivers' performance. Furthermore, the heterogeneity in the means caused by the DBQ subscale scores in OV and E in the presence of peripheral transverse lines indicates a difference in how drivers react to the countermeasures. The peripheral lines were more efficient than roadside poles to moderate speed but did not positively influence all drivers' trajectories. Although the peripheral lines could be seen as an alternative to change driver behavior in a non-challenging or monotonous road environment, the design used in this study should be reviewed.

[Social inequalities related to road traffic mortality]

OBJECTIVE

To synthesize the social inequalities related to mortality from traffic accidents reported in scientific publications.

METHOD

A scoping review following the PRISMA-ScR guide was carried out. Using the MesH vocabulary, we systematically searched for articles in English, Portuguese and Spanish published in the EBSCO, Scielo, Scopus, Ovid, and PubMed databases.

RESULTS

We identified 47,790 records in the initial search, of which 35 articles met the selection criteria. Nine out ten publications are in high-income countries; there is a greater interest in analyzing mortality in occupants and drivers of vehicles and motorcyclists. Half of the publications use race-ethnicity and geolocation as socioeconomic position variables. The articles included in this review indicate that groups of people with low socioeconomic positions have higher mortality due to traffic accidents.

CONCLUSIONS

The highest mortality from traffic accidents occurs in people with low socioeconomic positions which suggests the development of road safety actions from a comprehensive, integrative perspective and linked to other political agendas to reduce their incidence by 2030. Although road traffic fatalities are higher in low and middle-income countries, few publications are available in these countries. It is necessary to strengthen the research capacities in these countries.

Correlated random parameters model with heterogeneity in means for analysis of factors affecting the perceived value of road accidents and travel time

Road safety funding and management have become important issues in improving the quality of life of road users and there is evidence of a difference in driving behavior and the factor of road use between urban and rural areas, which is, in turn, reflected in different road safety evaluations. The purpose of this study is to assess the financial losses caused by road accidents on Thailand's highways and the related factors empirically, deploying the willingness-to-pay (WTP) approach. Data were obtained from 640 urban and 960 rural car drivers using a stated choice questionnaire and face-to-face interviews. This study used Correlated Random Parameters Binary Logit with Heterogeneity in Means (CRPBLHM) approach to analyze factors affecting WTP. According to the results, the value of a statistical life and injury for urban drivers was 1.63 times higher than that for rural drivers, and the value of travel time reduction per hour for urban drivers is ∼1.14 times higher than that found for rural drivers. Furthermore, the results of the CRPBLHM model reported that there are significant differences between urban and rural drivers' safety intentions and WTP. In the urban model, it was found that driving behavior (ticket, seatbelts, and speed) and weekday trips significantly increase the WTP, whereas household size and gender are unobserved characteristics among drivers. The rural model revealed that a driver's education (bachelor's and master's degrees held), and a necessary trip were significantly associated with drivers' valuation of safety; moreover, it was found that household size, sole earner status, own accident, in possession of a doctoral degree, and being young were significant in acting as unobserved characteristics. The results demonstrated differences in the value of road safety and unobserved heterogeneity among drivers, which influence risk perception and valuation with reference to the area context. Relevant agencies can use the results as a guideline for budget allocation and practical policy-related road safety management.

A deep learning approach for lane marking detection applying encode-decode instant segmentation network

A lot of people suffer from disability and death due to unintentional road accidents, which also result in the loss of a significant amount of financial assets. Several essential features of Advanced Driver Assistance Systems (ADAS) are being incorporated into vehicles by researchers to prevent road accidents. Lane marking detection (LMD) is a fundamental ADAS technology that helps the vehicle to keep its position in the lane. The current study employs Deep Learning (DL) methodologies and has several research constraints due to various problems. Researchers sometimes encounter difficulties in LMD due to environmental factors such as the variation of lights, obstacles, shadows, and curve lanes. To address these limitations, this study presents the Encode-Decode Instant Segmentation Network (EDIS-Net) as a DL methodology for detecting lane marking under various environmental situations with reliable accuracy. The framework is based on the E-Net architecture and incorporates combined cross-entropy and discriminative losses. The encoding segment was split into binary and instant segmentation to extract information about the lane pixels and the pixel position. DenselyBased Spatial Clustering of Application with Noise (DBSCAN) is employed to connect the predicted lane pixels and to get the final output. The system was trained with augmented data from the Tusimple dataset and then tested on three datasets: Tusimple, CalTech, and a local dataset. On the Tusimple dataset, the model achieved 97.39% accuracy. Furthermore, it has an average accuracy of 97.07% and 96.23% on the CalTech and local datasets, respectively. On the testing dataset, the EDIS-Net exhibited promising results compared to existing LMD approaches. Since the proposed framework performs better on the testing datasets, it can be argued that the model can recognize lane marking confidently in various scenarios. This study presents a novel EDIS-Net technique for efficient lane marking detection. It also includes the model's performance verification by testing in three different public datasets.

A Survey of Traumatic Brain Injuries from Road Traffic Collisions in a Lower Middle-Income Country

The burden of traumatic brain injury (TBI) from road traffic collisions (RTCs) is great in low-and middle-income countries (LMICs) due to shortfalls in preventative measures, and the lack of relevant, accurate data collection. To address this gap, we sought to study the epidemiology of TBI from RTCs in two LMIC neurosurgical centres in order to identify factors amenable to preventative strategies. A prospective survey of all adult and paediatric cases of TBI from RTCs admitted to Northwest General Hospital (NWGH) and Hayatabad Medical Complex (HMC) over a four-week period was carried out. Data on patient demographics, risk factors, injury details, pre-hospitalisation details, admission details and post-acute care was collected and analysed. A total of 68 patients were included in the study. 18 (26%) of the patients were male and in the 30 to 39 age group. Fifty-two percent were two-wheeler riders and/or passengers. 51 (75%) of the RTCs occurred between 12 noon and 12 midnight and in rural areas (66.2%). The most commonly documented risk factor that led to the RTC was speeding (35.3%). Pre-hospital care was either absent or undocumented. Up to two-thirds of patients were not direct transfers, and most were transported in private vehicles (48.5%) arriving later than an hour after injury (94.1%). Less than half with documented disabilities were referred for rehabilitation (38.5%). There are still gaps in the prevention of TBI from RTCs and in relevant data collection. Data collection systems must be strengthened, and further exploratory research carried out in order to improve the prevention of TBI from RTCs.

Crash severity analysis and risk factors identification based on an alternate data source: a case study of developing country

Road traffic injuries are one of the primary reasons for death, especially in developing countries like Bangladesh. Safety in land transport is one of the major concerns for road safety authorities and other policymakers. For this reason, contributory factors identification associated with crashes is necessary for reducing road crashes and ensuring transportation safety. This paper presents an analytical approach to identifying significant contributing factors of Bangladesh road crashes by evaluating the road crash data, considering three different severity levels (non-fetal, severe, and extremely severe). Generally, official crash databases are compiled from police-reported crash records. Though the official datasets are focusing on compiling a wide array of attributes, an assorted number of unreported issues can be observed that demands an alternative source of crash data. Therefore, this proposed approach considers compiling crash data from newspapers in Bangladesh which could be complimentary to the official crash database. To conduct the analysis, first, we filtered the useful features from compiled crash data using three popular feature selection techniques: chi-square, Two-way ANOVA, and Regression analysis. Then, we employed three machine learning classifiers: Decision Tree, Random Forest, and Naïve Bayes over the extracted features. A confusion matrix was considered to evaluate the proposed model, including classification accuracy, sensitivity, and specificity. The predictive machine learning model, namely, Random Forest using Label Encoder with chi-square and Two-way ANOVA feature selection process, seems the best option for crash severity prediction that provides high prediction accuracy. The resulting model highlights nine out of fourteen independent features as responsible factors. Significant features associated with crash severities include driver characteristics (gender, license type, seat belts), vehicle characteristics (vehicle type), road characteristics (road surface type, road classification), environmental conditions (day of crash occurred, time of crash), and injury localization. This outcome may contribute to improving traffic safety of Bangladesh.

Extreme environmental temperatures and motorcycle crashes: a time-series analysis

Extreme temperature could affect traffic crashes by influencing road safety, vehicle performance, and drivers' behavior and abilities. Studies evaluating the impacts of extreme temperatures on the risk of traffic crashes have mainly overlooked the potential role of vehicle air conditioners. The aim of this study, therefore, was to evaluate the effect of exposure to extreme cold and hot temperatures on seeking medical attention due to motorcycle crashes. The study was conducted in Iran by using medical attendance for motorcycle crashes from March 2011 to June 2017. Data on daily minimum, mean and maximum temperature (°C), relative humidity (%), wind velocity (km/h), and precipitation (mm/day) were collected. We developed semi-parametric generalized additive models following a quasi-Poisson distribution with the distributed nonlinear lag model to estimate the immediate and lagged associations (reported as relative risk [RR], and 95% confidence interval [CI]). Between March 2011 and June 2017, 36,079 medical attendances due to motorcycle road traffic crashes were recorded (15.8 ± 5.92 victims per day). In this time period, the recorded temperature ranged from -11.2 to 45.4 °C (average: 25.5 ± 11.0 °C). We found an increased risk of medical attendance for motorcycle crashes (based on maximum daily temperature) at both extremely cold (1st percentile) and hot (99th percentile) temperatures and also hot (75th percentile) temperatures, mainly during lags 0 to 3 days (e.g., RR: 1.12 [95% CI: 1.05: 1.20]; RR: 1.08 [95% CI: 1.01: 1.16]; RR: 1.20 [95% CI: 1.09: 1.32] at lag0 for extremely cold, hot, and extremely hot conditions, respectively). The risk estimates for extremely hot temperatures were larger than hot and extremely cold temperatures. We estimated that 11.01% (95% CI: 7.77:14.06) of the medical attendance for motorcycle crashes is estimated to be attributable to non-optimal temperature (using mean temperature as exposure variable). Our findings have important public health messaging, given the considerable burden associated with road traffic injury, particularly in low- and middle-income countries.

A Focus Group Study to Explore Risky Ridership among Young Motorcyclists in Manipal, India

Road crash injuries have emerged as a significant public health issue in many low and middle-income countries in recent years. In India, motorized two-wheelers comprise 70% of the vehicle population and are considered the most vulnerable road users. Road crash injury is common among the young-aged population leading to premature deaths. It is essential to understand risky riding behaviors to develop accurate, evidence-based risk reduction programmes that fit the target population’s characteristics and the intervention setting. The current study aims to improve the understanding of the typical characteristics of motorcycle crashes among young riders in India, primarily focusing on the prevalence and role of risky riding behaviors. Five focus group discussions with eight to ten participants in each group (N = 35) were conducted in Manipal, in the Karnataka state of Southwestern India. A thematic analysis was completed using MAXQDA software to identify, analyze, and report on themes within the data. Speeding, riding under the influence of alcohol, and the poor maintenance of motorcycles were indicated as leading causes of crashes. Furthermore, using mobile phones while riding, violations of the traffic rules, and helmet non-use were identified as other risky behaviors among young riders. Future research can be taken up in other settings for the target population. Generational awareness with the involvement of young riders, government authorities, university officials, and the Regional Transport Office can be initiated. Engaging young riders, government authorities, university officials, and the Regional Transport Office through behavioral interventions such as persuasive communication techniques, an active experimental approach (such as the use of a simulator), and regulating the licensing procedure can reduce the number of road crashes.

Road Safety Policies for Saudi Females: A Fuzzy Logic Analysis

Perceptions, attitudes and anticipated behavior represent very useful information for decision and policy makers before they implement proposed new policies. Road safety is one of the most critical fields in the built environment. In the Kingdom of Saudi Arabia, women started driving in 2019. There is a huge shortage of studies that investigate users’ attitudes and behavior, particularly women, in Saudi Arabia. It is very timely therefore, to assess their perceptions, attitudes and raise their awareness towards road safety. In this paper, the perceptions and attitudes towards road safety and relevant policies and programs were assessed and compared using two approaches: analytical and a fuzzy logic system. By means of a questionnaire, a total of 17 road safety policies, including engineering, enforcement programs, education programs and legislation programs, were presented to the participants and assessed. These policies were assessed from the viewpoint of Saudi women. The engineering policies included the use of road signs and marking, improving road network alignment, monitoring driver speed and engineering speed reduction measures. The assessment was in terms of the usefulness of the policies to reduce traffic accidents and improve road safety in Riyadh. A total of 375 participants were surveyed. Using a Likert scale response system to report the Saudi female participants’ opinions, two sets of indices were calibrated to evaluate the perceived usefulness and acceptability of the safety policies. A MATLAB simulation of a fuzzy logic system was utilized to assess, investigate and compare travel attitudes and perceptions of road safety. The results indicate overall encouragement for the safety programs and policies by the participants. Most of the support seems to be for the engineering program. The physical presence of traffic police was observed to have scored the highest. This is an interesting result that shows that enforcement policies are still perceived to be the most effective. In this category, the policy of enforcing speed limits showed high support, amongst the other policies. While a fuzzy logic analysis is typically used in hard engineering assessments and investigations, such as mechanical engineering and system design applications, the results obtained in this investigation show that the efficacy and adequacy of the proposed fuzzy logic control system in assessing attitudinal data was sufficiently good to be recommended for future research. The outcomes from both sets of approaches, the analytical and the fuzzy logic, showed comparable results, which also demonstrates the potential benefits of using the fuzzy system in many attitudinal and behavioral studies.

The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

BACKGROUND

Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

AIM

To assess the spectrum and burden of paediatric MSD in children aged 5-18 years admitted to a major referral hospital in Tanzania.

METHODS

This was a retrospective cohort study of children aged 5-18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

RESULTS

During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5-18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

CONCLUSION

The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.

ABBREVIATION

CI: confidence interval; HIC: high-income countries; HIV: human immunodeficiency virus; ICD-10: International Classification of Diseases 10; IQR: interquartile range; JIA: juvenile idiopathic arthritis; KCMC: Kilimanjaro Christian Medical Centre; LMIC: low- and middle-income countries; MSD: musculoskeletal diseases: NAI: non-accidental injury; NIHR: National Institute for Health Research; PAFLAR: Paediatric Society of the African League Against Rheumatism; RTA: road traffic accidents; SCD: sickle cell disease; SLE: systemic lupus erythematosus; SSA: sub-Saharan Africa.

Visual Impairment and Risk of Self-Reported Road Traffic Crashes Among Bus Drivers in Bangladesh

PURPOSE

This study assesses the prevalence and the causes of visual impairment among bus drivers undergoing screening in Bangladesh and associations with self-reported crashes.

METHODS

Eye health screenings including refraction and questionnaires were conducted at 10 bus terminals in 7 districts of Bangladesh from June through August 2019. Presenting near and distance visual impairment and self-reported road traffic crashes were recorded.

RESULTS

Among 700 participants, nearly 1 in 5 (n = 126, 18.0%) had presented visual acuity (VA) in the better-seeing eye ≤6/9, not meeting the vision standard of Bangladesh for bus drivers. A majority of drivers (n = 492, 70.3%) had near or distance refractive error, and most who failed to reach the driving standard (88.1%, n = 111) could be improved with readily available treatment, either glasses or cataract surgery. A history of 1 or more road traffic crashes while driving a bus or minibus was reported by 62 (8.97%) participants. In multivariable models, factors significantly associated with near or distance visual impairment included older age [odds ratio (OR) per year 1.15, 95% confidence interval (CI): 1.12-1.18, P < 0.0001] and having no driver's license (OR 1.80, 95% CI: 1.04-3.13, P = 0.037). Self-reported history of a motor vehicle crash was associated with near or distance visual impairment (OR 2.45, 95% CI: 1.09-5.49, P = 0.030), even when adjusting for other factors such as age and weekly miles are driven.

CONCLUSIONS

Ensuring that bus drivers are screened to meet the required visual standards for driving while referring those who do not for treatment, can contribute to safer roads in this high-risk setting.

Application and Evaluation of a Non-Accident-Based Approach to Road Safety Analysis Based on Infrastructure-Related Human Factors

Too often the identification of critical road sites is made by “accident-based” methods that consider the occurred accidents’ number. Nevertheless, such a procedure may encounter some difficulties when an agency does not have reliable and complete crash data at the site level (e.g., accidents contributing factors not clear or approximate accident location) or when crashes are underreported. Furthermore, relying on accident data means waiting for them to occur with the related consequences (possible deaths and injuries). A non-accident-based approach has been proposed by PIARC. This approach involves the application of the Human Factors Evaluation Tool (HFET), which is based on the principles of Human Factors (HF). The HFET can be applied to road segments by on-site inspections and provides a numerical performance measure named Human Factors Scores (HFS). This paper analyses which relationship exists between the results of the standard accident-based methods and those obtainable with HFET, based on the analysis of self-explaining and ergonomic features of the infrastructure. The study carried out for this purpose considered 23 km of two-way two-lane roads in Italy. A good correspondence was obtained, meaning that high risky road segments identified by the HFS correspond to road segments already burdened by a high number of accidents. The results demonstrated that the HFET allows for identifying of road segments requiring safety improvements even if accident data are unavailable. It allows for improving a proactive NSS, avoiding waiting for accidents to occur.

Fatality risk and issues of inequity among vulnerable road users in South Africa

Background

Contextual effects from the physical and social environment contribute to inequitable protection for a large proportion of road users, especially in low- and middle-income countries like South Africa where distorted urban planning and socio-spatial disparities from the apartheid era prevail.

Objectives

This paper examines the differentiated risk of road traffic crashes and injuries to vulnerable road users in South Africa, including pedestrians, females and users of some modes of public transport, in relation to characteristics of the crashes that proxy a range of contextual influences such as rurality and socio-economic deprivation.

Methods

The study is based on a descriptive analysis of 33 659 fatal crashes that occurred in South Africa over a three-year period from 2016–2018. Measures of simple proportion, population-based fatality rate, “impact factor” and crash severity are compared between disaggregated groups using Chi-Square analysis, with the Cramer’s V statistic used to assess effect size.

Results and significance

Key findings show a higher pedestrian risk in relation to public transport vehicles and area-level influences such as the nature of roads or extent of urbanity; higher passenger risk in relation to public transport vehicles and rurality; and higher risk for female road users in relation to public transport vehicles. The findings have implications for prioritising a range of deprivation-related structural effects. In addition, we present a “User-System-Context” conceptual framework that allows for a holistic approach to addressing vulnerability in the transport system. The findings provide an important avenue for addressing the persistently large burden of road traffic crashes and injuries in the country.

Out-of-pocket payments and catastrophic expenditures due to traffic injuries in Ouagadougou, Burkina Faso

OBJECTIVE

To estimate the out-of-pocket expenditures linked to Road Traffic Injuries in Ouagadougou, Burkina Faso, as well as the prevalence of catastrophic expenditures among those out-of-pocket payments, and to identify the socio-economic determinants of catastrophic expenditures due to Road Traffic Injuries.

METHODS

We surveyed every admission at the only trauma unit of Ouagadougou between January and July 2015 at the time of their admission, 7 days and 30 days later. We estimate a total amount of out-of-pocket expenditures paid by each patient. We considered an expense as catastrophic when it represented 10% at least of the annual global consumption of the patient's household. We used linear models to determine if socio-economic characteristics were associated to a greater or smaller ratio between out-of-pocket payment and global annual consumption.

FINDINGS

We surveyed 1323 Road injury victims three times (admission, Days 7 and 30). They paid in average 46,547 FCFA (83.64 US dollars) for their care, which represent a catastrophic expenditure for 19% of them. Less than 5% of the sample was covered by a health insurance scheme. Household economic status is found to be the first determinant of catastrophic health expenditure occurrence, exhibiting a significant and negative on the ratio between road injury expenditures and global consumption.

CONCLUSION

Our findings highlight the importance of developing health insurance schemes to protect poor households from the economic burden of road traffic injuries and improve equity in front of health shocks.

The Epidemiology of Injuries in Adults in Nepal: Findings from a Hospital-Based Injury Surveillance Study

This study aimed to develop and evaluate a model of hospital-based injury surveillance and describe the epidemiology of injuries in adults. One-year prospective surveillance was conducted in two hospitals in Hetauda, Nepal. Data were collected electronically for patients presenting to emergency departments (EDs) with injuries between April 2019 and March 2020. To evaluate the model’s sustainability, clinical leaders, senior managers, data collectors, and study coordinators were interviewed. The total number of patients with injuries over one year was 10,154, representing 30.7% of all patients visiting the EDs. Of patients with injuries, 7458 (73.4%) were adults aged 18 years and over. Most injuries (6434, 86%) were unintentional, with smaller proportions due to assault (616, 8.2%) and self-harm (408, 5.5%). The median age of adult patients was 33 years (IQR 25–47). Males had twice the rate of ED presentation compared with females (40.4 vs. 20.9/1000). The most common causes were road traffic accidents (32.8%), falls (25.4%), and animal/insect related injuries (20.1%). Most injured patients were discharged after treatment (80%) with 9.1% admitted to hospital, 8.1% transferred to other hospitals, and 2.1% died. In Nepal, hospital-based injury surveillance is feasible, and rich injury data can be obtained by embedding data collectors in EDs.

Road safety and heavy goods vehicle driving in LMICs: Qualitative evidence from Nepal

BACKGROUND

Heavy goods vehicle drivers are an influential driving population in Nepal, with over 90% of goods in the country are transported by road. Due to the time spent on the road, drivers have long periods of exposure to the risk of crash involvement. The study explores the perceptions and experiences of heavy goods vehicle drivers and representatives from their professional association regarding road danger.

METHODS

We conducted semi-structured interviews with fifteen heavy goods vehicle drivers regularly driving on the East-West highway of Makwanpur District, Nepal. A focus group was conducted with eleven members from a major transportation entrepreneur's association in Nepal. The focus group and interviews were audio-recorded, transcribed, translated, and analyzed using thematic analysis.

RESULTS

Four themes were developed- assumptions of blame; perceptions of safety culture in the trucking industry; influence of road infrastructure; and behaviours of road users. The road and traffic environment, enforcement, and the safety culture in the heavy vehicle industry not only influenced the attitudes of the road users towards traffic safety but also legitimized and encouraged behaviours that affect safety. General and industry-related road safety improvements suggested by participants included: making provision for heavy good vehicles parking areas, separating the highway with a median strip, improving crash investigation capacity, conducting road safety awareness and training programs, strictly enforcing the speed limit and laws about driving under the influence of alcohol/drugs, and formulating strategies to create a safe, supportive working environment in the heavy vehicle industry.

CONCLUSION

Heavy goods vehicle drivers and members of the professional association can provide rich information regarding the barriers and facilitators of road risk in Nepal. Their perceptions and opinions can contribute to devising interventions at individual, societal, organizational, and governmental levels, and inform efforts to develop a positive safety culture within the heavy vehicle transport industry.

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.

Vision impairment and traffic safety outcomes in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Road traffic injuries are a major public health concern and their prevention requires concerted efforts. We aimed to systematically analyse the current evidence to establish whether any aspects of vision, and particularly interventions to improve vision function, are associated with traffic safety outcomes in low-income and middle-income countries (LMICs).

METHODS

We did a systematic review and meta-analysis to assess the association between poor vision and traffic safety outcomes. We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials in the Cochrane Library from database inception to April 2, 2020. We included any interventional or observational studies assessing whether vision is associated with traffic safety outcomes, studies describing prevalence of poor vision among drivers, and adherence to licensure regulations. We excluded studies done in high-income countries. We did a meta-analysis to explore the associations between vision function and traffic safety outcomes and a narrative synthesis to describe the prevalence of vision disorders and adherence to licensure requirements. We used random-effects models with residual maximum likelihood method. The systematic review protocol was registered on PROSPERO, CRD-42020180505.

FINDINGS

We identified 49 (1·8%) eligible articles of 2653 assessed and included 29 (59·2%) in the various data syntheses. 15 394 participants (mean sample size n=530 [SD 824]; mean age of 39·3 years [SD 9·65]; 1167 [7·6%] of 15 279 female) were included. The prevalence of vision impairment among road users ranged from 1·2% to 26·4% (26 studies), colour vision defects from 0·5% to 17·1% (15 studies), and visual field defects from 2·0% to 37·3% (ten studies). A substantial proportion (range 10·6-85·4%) received licences without undergoing mandatory vision testing. The meta-analysis revealed a 46% greater risk of having a road traffic crash among those with central acuity visual impairment (risk ratio [RR] 1·46 [95% CI 1·20-1·78]; p=0·0002, 13 studies) and a greater risk among those with defects in colour vision (RR 1·36 [1·01-1·82]; p=0·041, seven studies) or the visual field (RR 1·36 [1·25-1·48]; p<0·0001, seven studies). The I2 value for overall statistical heterogeneity was 63·4%.

INTERPRETATION

This systematic review shows a positive association between vision impairment and traffic crashes in LMICs. Our findings provide support for mandatory vision function assessment before issuing a driving licence.

FUNDING

None.

Investigating factors affecting bus/minibus accident severity in a developing country for different subgroup datasets characterised by time, pavement, and light conditions

Developing countries are primarily associated with poor roadway and lighting infrastructure challenges, which has a considerable effect on their traffic accident fatality rates. These rates are further increased as bus/minibus drivers indulge in risky driving, mainly during weekends when traffic and police surveillance is low to maximise profits. Although these factors have been mentioned in the literature as key indicators influencing accident severity of buses/minibuses, there is currently no study that explored the complex mechanisms underpinning the simultaneous effect of pavement and light conditions on the generation of accident severity outcomes while considering weekly temporal stability of the accident-risk factors. This study seeks to investigate the variations in the effect of contributing factors on the severity of bus/minibus accidents in Ghana across various combinations of pavement and light conditions and to identify the exact effects of weekdays and weekends on severity outcomes using a random parameter ordered logit model with heterogeneity in the means to account for unobserved heterogeneity in the police-reported data. Preliminary analysis demonstrated that accident-risk factors used in the models were temporally unstable, warranting the division of the data into both weekend and weekday time-periods. A wide variety of factors such as sideswipes, median presence, merging, and overtaking had significantly varying effects on bus/minibus accident severities under different combinations of pavement and light conditions for both weekdays and weekends. Insights drawn from this study, together with the policy recommendations provided, can be employed by engineers and policymakers to improve traffic safety in developing nations.

Road Safety as a Public Health Problem: Case of Ecuador in the Period 2000–2019

Background: Road safety is a significant public health problem because it causes negative consequences on victims and families. The objective was to analyze the most significant changes in traffic crashes in Ecuador during the period from 2000 to 2019. With data obtained from the National Institute of Statistics and Census, we performed the analysis to identify: the number of traffic crashes, the number of victims, and other study variables. Methods: Descriptive and analytical statistics and the contrast of proportions were used to analyze data from 2000 to 2019. Results: According to the ideal joinpoint analysis model, there was a significant decrease in the number of recorded traffic accidents from 2015 to 2019 of −8.54 per year, while the tendency to die increased in females (2.05 per year) and males (3.29 per year). The most common crash was a collision, and the automobile appeared as the most involved vehicle from 2015 to 2019. The hypothesis test contrast is used to determine if statistically significant differences exist between age groups by gender of the driver injured in the period 2017–2018. Conclusions: This study determines the most significant changes in the variables related to traffic crashes, where mortality due to this cause in the last four years has had a growth rate of 1.8% compared to collisions that presented a rate of −31.12%. The contrast of the hypothesis test shows significant differences in the injury level between males and female drivers, depending on the age group.

Resolving the differences between system development and system operation using STAMP: a road safety case study in a low-income setting

Road safety strategies adopted worldwide have made significant progress in reducing road trauma, but have stagnated more recently. The situation in low- and middle-income countries is even worse with no significant decrease in fatality rates. Safety researchers have argued that adopting sociotechnical systems approach is necessary to make significant advancements and improvements. The aim of this study was to develop a control structure model of the Bangladesh road safety system by identifying the actors and organisations involved across the system. Expert stakeholders were identified and interviewed, and relevant information was gathered in order to generate the Systems Theoretic Accident Model and Process control structure model. Throughout the analysis of this model, differences in the control and feedback mechanisms of the system were identified, and road safety intervention recommendations were made. Future research should also predict potential risks within the system and propose proactive and preventative countermeasures. Practitioner summary: In this article, a Systems Theoretic Accident Model and Process control structure model of the Bangladesh road safety system is developed, and the involved actors are identified. Based on interviews and workshops with expert stakeholders, differences in the controls and feedback mechanisms in the system were identified, and road safety intervention recommendations were made. Abbreviations: BUET: Bangladesh University of Engineering and Technology.

An exploratory qualitative study of the prevention of road traffic collisions and neurotrauma in India: perspectives from key informants in an Indian industrial city (Visakhapatnam)

BACKGROUND

Despite current preventative strategies, road traffic collisions (RTCs) and resultant neurotrauma remain a major problem in India. This study seeks to explore local perspectives in the context within which RTCs take place and identify potential suggestions for improving the current status.

METHODS

Ten semi-structured interviews were carried out with purposively selected key informants from the city of Visakhapatnam, Andhra Pradesh. Participants were from one of the following categories: commissioning stakeholders; service providers; community or local patient group/advocacy group representatives. Transcripts from these interviews were analysed qualitatively using the Framework Method.

RESULTS

Participants felt RTCs are a serious problem in India and a leading cause of neurotrauma. Major risk factors identified related to user behaviour such as speeding and not using personal safety equipment, and the user state, namely drink driving and underage driving. Other reported risk factors included poor infrastructure, moving obstacles on the road such as other vehicles, pedestrians and animals, overloaded vehicles and substandard safety equipment. Participants discussed how RTCs affect not only the health of the casualty, but are also a burden to the healthcare system, families, and the national economy. Although there are ongoing preventative strategies being carried out by both the government and the community, challenges to successful prevention emerged from the interviews which included resource deficiencies, inconsistent implementation, lack of appropriate action, poor governance, lack of knowledge and the mindset of the community and entities involved in prevention. Recommendations were given on how prevention of RTCs and neurotrauma might be improved, addressing the areas of education and awareness, research, the pre-hospital and trauma systems, enforcement and legislation, and road engineering, in addition to building collaborations and changing mindsets.

CONCLUSIONS

RTCs remain a major problem in India and a significant cause of neurotrauma. Addressing the identified gaps and shortfalls in current approaches and reinforcing collective responsibility towards road safety would be the way forward in improving prevention and reducing the burden.

Representing two road traffic collisions in one Accimap: highlighting the importance of emergency response and enforcement in a low-income country

Seemingly erratic pedestrian crossing has become a major source of vehicle-pedestrian collisions on highways in Bangladesh, and across other low- and middle-income countries (LMICs). In this article, we approach the challenge from a sociotechnical systems perspective by using the Accimap method to analyse a pair of time-separated yet interconnected road traffic collisions. The first event involved a truck colliding with a road divider; in the second, fatal incident, a bus hit a university student. The traditional-style investigation conducted immediately after the collision apportioned blame to end users, that is, drivers and pedestrian; however, application of sociotechnical systems thinking revealed the contribution from lack of emergency response and enforcement among many other important factors. Results and recommendations are discussed in terms of reducing the chance and severity of such collisions across LMICs, and in terms of the need to look beyond the end-user, a focus that remains dominant in such settings. Practitioner summary: This paper applies sociotechnical systems thinking to pedestrian safety in Bangladesh by analysing two inter-connected road traffic collisions using a single Accimap. The findings emphasise the importance of implementing road safety interventions that target all system levels, and draw attention to the importance of post-collision response in low-income settings. Abbreviation: BUET: Bangladesh University of Engineering and Technology.

The Complexity of Space Utilization and Environmental Pollution Control in the Main Corridor of Makassar City, South Sulawesi, Indonesia

Population mobility, increasing demand for transportation, and the complexity of land use have an impact on environmental quality degradation and air quality pollution. This study aims to analyze (1) the effect of population mobility, increased traffic volume, and land use change on air quality pollution, (2) direct and indirect effects of urban activities, transportation systems, and movement patterns on environmental quality degradation and air pollution index, and (3) air pollution strategy and sustainable urban environmental management. The research method used is a sequential explanation design. Data were obtained through observation, surveys, in-depth interviews, and documentation. The results of the study illustrate that the business center and Daya terminal with a value of 0.18 µgram/m3 is polluted, the power plant and Sermani industrial area with a value of 0.16 µgram/m3 is polluted, the Makassar industrial area with a value of 0.23 is heavily polluted, and the Hasanuddin International Airport area with a value of 0.04 µgram/m3 is not polluted. Population mobility, traffic volume, and land use changes have a significant effect on environmental quality degradation, with a determination coefficient of 94.1%. The direct effect of decreasing environmental quality on the air pollution index is 66.09%. This study recommends transportation management on the main road corridor of Makassar City, which is environmentally friendly with regard to sustainable environmental management.

State-of-the-art review: preventing child and youth pedestrian motor vehicle collisions: critical issues and future directions

Aim

To undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies.

Methods

Articles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards).

Results

This state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration).

Conclusions

Research conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.

Identifying the Factors That Increase the Probability of an Injury or Fatal Traffic Crash in an Urban Context in Jordan

The lack of robust studies carried out on urban roads in developing countries makes it difficult to enhance traffic safety, ensuring sustainable roads and cities. This study analyzes the contribution of a number of explanatory variables behind crashes involving injuries on arterial roads in Irbid (Jordan). Five binary logistic regression models were calibrated for a crash dataset from 2014–2018: one for the full database, and the others for the four main crash causes identified by Jordanian Traffic Police reports. The models show that whatever the crash cause, the three most significant factors linked to an injury or fatality lie in urban road sections that are in large-scale neighborhood areas, have fewer than six accesses per kilometer, and have a low traffic volume (under 500 veh/h/ln). Some of these results agree with previous studies in other countries. Jordan’s governmental agencies concerned with urban road safety might use these results to develop appropriate plans and implement priority actions for each crash cause, in addition to undertaking further research for comparative purposes.

Complex relationship between household wealth, location of residence, road crash injury incidence and injury severity in Uganda

BACKGROUND

Limited evidence exists about associations between road crash injury and economic status in sub-Saharan Africa from large, population-based data sets. Existing studies generally do not incorporate fatal crashes. This study aims to understand the relationship between relative wealth and road crash injury and severity using population-representative cross-sectional data from Uganda's 2016 Demographic and Health Survey .

METHODS

One-year road crash risk was flexibly modelled as a function of wealth using fractional polynomial models, stratified by sex and rural/urban residence. Wealth was operationalised as 1/20th quantiles of the first principal component from a polychoric principal component analysis. Injury severity was coded as a three-level ordinal variable; associations with wealth were modelled with ordinal logistic regression on quintiles of relative wealth, stratified by residence.

RESULTS

Overall, injury risk peaked in the upper middle of the wealth distribution. Rural resident injury risk increased monotonically with wealth. Urban resident risk had an upside-down U shape. Risk peaked in the distribution's middle at about double the lowest levels. Only urban men had higher risk among the least wealthy than most wealthy (3.2% vs 1.7%; difference=1.5 percentage points, 95% CI 0.2 to 2.7). Among those with road crash injuries, greater relative wealth was associated with decreased likelihood of more severe injury (33.2 percentage points lower in the highest category than lowest, 95% CI 18.4 to 48.1) or death (5.9 percentage points, 95% CI -0.1 to 11.8) for urban residents but not rural residents.

CONCLUSION

Relationships between relative wealth and injury risk and severity are complex and different for urban and rural Ugandans.

Disability, Mobility and Transport in Low- and Middle-Income Countries: A Thematic Review

This paper discusses issues affecting the transport and mobility needs of people with disabilities in middle- and low-income countries and how disability intersects with a range of other factors to impact on transport needs, use and engagement. The paper is intended to stimulate discussion and identify areas for further research, and identifies a number of key issues that are salient to discussions around equitable and inclusive transport provision, including patterns of transport use, behaviour and experiences, solutions and policy directions, measuring access and inclusion, policies and intersectionality. The paper also identifies gaps in knowledge and provision, barriers to addressing these gaps, and some possible solutions to overcoming these barriers. These include shifting the focus from access to inclusion, reconceptualising how ‘special’ transport might be provided, and most importantly listening to the voices and experiences of adults and children with disabilities. Despite lack of transport often being cited as a reason for lack of inclusion of people with disabilities, there is surprisingly little evidence which either quantifies this or translates what this lack of access means to people with disabilities in their daily lives in low- and middle-income countries.