Evaluation of the five-year Bloomberg Philanthropies Global Road Safety Program in the Russian Federation

Road traffic injuries are a leading cause of morbidity and mortality in the world. In Russia, a road safety program was implemented in Lipetskaya and Ivanovskaya oblasts (regions) as part of a 10-country effort funded by Bloomberg Philanthropies. The program was focused on increasing seat belt and child restraint use and reducing speeding. The primary goals of this monitoring and evaluation study are to assess trends in seat belt use, child restraint use, and speed compliance in the two oblasts over the 5 years and to explore the overall impact of the program on road traffic injury and death rates. Primary data via roadside observations and interviews, and secondary data from official government sources were collected and analyzed for this study. Our results indicate significant improvements in seat belt wearing and child seat use rates and in prevalence of speeding in both intervention oblasts. The observations were consistent with the results from the roadside interviews. In Lipetskaya, restraint use by all occupants increased from 52.4% (baseline, October 2010) to 77.4% (final round, October 2014) and child restraint use increased from 20.9% to 54.1% during the same period. In Ivanovskaya, restraint use by all occupants increased from 48% (baseline, April 2012) to 88.7% (final round, October 2014) and child restraint use increased from 20.6% to 89.4% during the same period. In Lipetskaya, the overall prevalence of speeding (vehicles driving above speed limit) declined from 47.0% (baseline, July 2011) to 30.4% (final round, October 2014) and a similar pattern was observed in Ivanovskaya where the prevalence of speeding decreased from 54.6% (baseline, March 2012) to 46.6% (final round, October 2014). Through 2010-2014, the road traffic crash and injury rates per 100,000 population decreased in Lipetskaya oblast (191.5 and 246.9 in 2010 and 170.4 and 208.6 in 2014, respectively) and slightly increased in Ivanovskaya oblast (184.4 and 236.0 in 2010 and 186.7 and 243.4 in 2014, respectively). These road safety improvements are associated with the program that enabled a combined focus on policy reform, legislation, enforcement, advocacy, education, and data collection and use. However, the existence of other road safety efforts, lack of data from comparable regions, and unavailability of risk factor-specific data make it difficult to attribute these changes to the program.

Potential gains in life expectancy by improving road safety in China

OBJECTIVES

Road traffic injuries (RTI) cause a significant number of injuries and deaths in China every year; the World Health Organization estimated 261,367 deaths due to RTI in 2013. As a result of the ongoing growth of China's economy, road construction and motorisation, RTI are expected to impose a heavy health burden in the future. However, the public and policy makers have not widely perceived RTI as a public health issue commensurate with its consequences, in part, due to a lack of intuitive indicator measuring the health impact.

STUDY DESIGN

Employs the cause-eliminating life table technique to provide a measure of the burden of RTI based on data from a nationally representative surveillance system in China.

METHODS

Previous studies have used indicators such as event counts, rates and disability-adjusted life years to measure the health impact of RTI; but this study uses potential gains in life expectancy to measure this impact.

RESULTS

Eliminating RTI could lead to a gain of 0.52 years in life expectancy in 2012, meaning that on average Chinese people could live a half year more than they would in the presence of RTI. Males have a substantially higher RTI death rate and consequently could have a gain in life expectancy more than twice as large as females (male 0.72 years vs female 0.28 years). The gain in rural areas (0.65 years) is twice that in urban areas (0.32 years).

CONCLUSIONS

The significant gain in life expectancy signals the urgency for public actions to improve road safety; the disparity in the burden across regions and sexes indicate a great opportunity for targeted interventions to protect health and save lives.

Evaluation of a five-year Bloomberg Global Road Safety Program in Turkey

OBJECTIVE

Turkey was included in the Bloomberg Philanthropies funded Global Road Safety Program (2010-14) with Ankara and Afyonkarahisar (Afyon) selected for interventions to manage speed and encourage seat-belt use. The objectives of this study are to present the monitoring and evaluation findings of seat-belt use and speed in Afyon and Ankara over the five years and to assess overall impact of the program on road traffic injury, and death rates in Turkey.

STUDY DESIGN

Quasi-experimental before after without comparison.

METHODS

In collaboration with the Middle East Technical University, roadside observations and interviews were coupled with secondary data to monitor changes in risk factors and outcomes at the two intervention sites.

RESULTS

The percentage of seat-belt use among drivers and front-seat passengers in Afyon and Ankara increased significantly between 2010 and 2014 with increased self-reported use and preceded by an increase in tickets (fines) for not using seat belts. There were uneven improvements in speed reduction. In Afyon, the average speed increased significantly from 46.3 km/h in 2012 to about 52.7 km/h in 2014 on roads where the speed limits were 50 km/h. In Ankara, the average speed remained less than 55 km/h during the program period (range: 50-54 km/h; P < 0.005) for roads where the speed limits were 50 km/h; however, the average speed on roads with speed limits of 70 km/h decreased significantly from 80.6 km/h in 2012 to 68.44 km/h in 2014 (P < 0.005).

CONCLUSION

The program contributed to increase in seat-belt use in Afyon and Ankara and by drawing political attention to the issue can contribute to improvements in road safety. We are optimistic that the visible motivation within Turkey to substantially reduce road traffic injuries will lead to increased program implementation matched with a robust evaluation program, with suitable controls.

A comparison of observed and self-reported helmet use and associated factors among motorcyclists in Hyderabad city, India

OBJECTIVES

India has a high burden of fatal road traffic injuries (RTIs). A large proportion of fatal RTIs in India are among motorcyclists. The overall goal of this study is to assess and compare observed and self-reported prevalence of helmet use; and to identify factors associated with helmet use and over-reporting in Hyderabad city, India.

STUDY DESIGN

Roadside knowledge, attitude and practice interviews.

METHODS

Six rounds of roadside interviews were conducted with motorcyclists (drivers and pillion riders) between July 2011 and August 2013 using a structured tool developed for this study. Observations on helmet use were recorded and respondents were also asked if they 'always wear a helmet'. Prevalence of helmet use was calculated and a paired t-test was used to compare observed and self-reported helmet use proportions. Unadjusted and adjusted odds ratios were calculated to identify factors associated with helmet use and over-reporting.

RESULTS

A total of 4872 respondents participated in the roadside interview. The response rate was 94.4%. The overall observed helmet use was 34.5% and 44.5% of respondents reported that they 'always wear a helmet'. As the observed helmet use increased, the over-reporting of helmet use was found to decrease. However, factors associated with observed and self-reported helmet use are similar. Male gender, youth (≤24 years), a lower level of education and non-ownership of helmet were associated with a higher risk of not wearing helmets. Male gender, youth (≤24 years), no schooling, riding a lower engine capacity motorcycle and using a motorcycle for purposes other than travelling to school/work were associated with over-reporting of helmet use.

CONCLUSIONS

Self-reports provide an overestimate of helmet use that lessens as actual helmet use increases. Interviews also allow identification of factors associated with helmet use. Increasing helmet ownership and enhanced enforcement may help increase helmet use.

Comparative analysis of three prehospital emergency medical services organizations in India and Pakistan

OBJECTIVES

Strengthened emergency medical services (EMS) are urgently required in South Asia to reduce needless death and disability. Several EMS models have been introduced in India and Pakistan, and research on these models can facilitate improvements to EMS in the region. Our objective was to conduct a cross-case comparative analysis of three EMS organizations in India and Pakistan - GVK EMRI, Aman Foundation and Rescue 1122 - in order to draw out similarities and differences in their models.

STUDY DESIGN

Case study methodology was used to systematically explore the organizational models of GVK EMRI (Karnataka, India), Aman Foundation (Karachi, Pakistan), and Rescue 1122 (Punjab, Pakistan).

METHODS

Qualitative methods - interviews, document review and non-participant observation - were utilized, and using a process of constant comparison, data were analysed across cases according to the WHO health system 'building blocks'.

RESULTS

Emergent themes under each health system 'building block' of service delivery, health workforce, medical products and technology, health information systems, leadership and governance, and financing were described. Cross-cutting issues not applicable to any single building block were further identified.

CONCLUSIONS

This cross-case comparison, the first of its kind in low- and middle-income countries, highlights key innovations and lessons, and areas of further research across EMS organizations in India, Pakistan and other resource-poor settings.

The challenges of injuries and trauma in Pakistan: an opportunity for concerted action

Injuries and trauma are a major cause of mortality and morbidity in low and middle income countries (LMICs). In Pakistan, a low income South Asian developing country, they are among the top ten contributors to disease burden and causes of disabilities, with the majority of the burden falling on younger people in the population. This burden of injuries comes with a high social and economic cost. Several distal and proximal determinants, such as poverty, political instability, frequent natural disasters, and the lack of legislation and enforcement of preventive measures, make the Pakistani population susceptible to injuries. Historically, there has been a low level of investment in the prevention of injuries in Pakistan. Data is limited and while a public sector surveillance project has been initiated in one major urban centre, the major sources of information on injuries have been police and hospital records. Given the cost-effectiveness of injury prevention programs and their success in other LMICs, it is essential that the public sector invest in injury prevention through improving national policies and creating a strong evidence-based strategy while collaborating with the private sector to promote injury prevention and mobilizing people to engage in these programs.

Road traffic injuries and data systems in Egypt: addressing the challenges

OBJECTIVE

Road traffic injuries (RTIs) are a major cause of global mortality and morbidity, killing approximately 1.3 million people and injuring 20 to 50 million each year. The significance of this public health threat is most pronounced in low- and middle-income countries where 90 percent of the world's road traffic-related fatalities take place. Current estimates for Egypt show a road traffic fatality rate of 42 deaths per 100,000 population-one of the highest in the Eastern Mediterranean Region. RTIs are also responsible for 1.8 percent of all deaths and 2.4 percent of all disability-adjusted life years (DALYs) lost in the country. Despite this, studies surrounding this topic are scarce, and reliable data are limited. The overall goal of this article is to define the health impact of RTIs in Egypt and to identify the strengths and weaknesses of each data source for the purpose of improving the current RTI data systems.

METHODS

A 2-pronged approach was undertaken to assess the burden of RTIs in Egypt. First, a thorough literature review was performed using PubMed, Embase, ISIS Web of Knowledge, and Scopus databases. Articles pertaining to Egypt and road traffic injuries were selected for screening. With assistance from Egyptian colleagues, a comprehensive exploration of data sources pertaining to RTIs in Egypt was undertaken and secondary data from these sources were procured for analysis.

RESULTS

The literature review yielded a total of 20 studies, of which 6 were multi-country and 5 were hospital-based studies. None examined risk factors such as speeding, alcohol, or seat belt use. Secondary data sources were acquired from national hospital-based injury surveillance; a community-based health survey; pre-hospital injury surveillance; the Ministry of Transport; the General Authority for Roads, Bridges and Land Transport; death certificates; and the central agency for public motorization and statistics. Risk factor data are also limited from these sources.

CONCLUSION

The results of this article clearly highlight the significant burden that road traffic injuries pose on the health of the Egyptian population. The hospital-based injury surveillance system that has been established in the country and the use of International Classification of Diseases (ICD-10) coding brings the system very closely in line with international guidelines. There is, however, some considerable room for improvement, including the need to extend the coverage of the surveillance system, the inclusion of injury severity scores and disability indicators, and standardization of the sometimes rather disparate sources from various sectors in order to maximally capture the true burden of RTIs.

Potential Risk Estimation Drowning Index for Children (PREDIC): a pilot study from Matlab, Bangladesh

Childhood drowning is a major public health problem that has been neglected in many low- and middle-income countries. In Matlab, rural Bangladesh, more than 40% of child deaths aged 1-4 years are due to drowning.

AIM

The main objective of this paper was to develop and evaluate a childhood drowning risk prediction index.

METHODOLOGY

A literature review was carried out to document risk factors identified for childhood drowning in Bangladesh. The Newacheck model for special health care needs for children was adapted and applied to construct a childhood drowning risk index called "Potential Risk Estimation Drowning Index for Children" (PREDIC). Finally, the proposed PREDIC Index was applied to childhood drowning deaths and compared with the comparison group from children living in Matlab, Bangladesh. This pilot study used t-tests and Receiver Operating Characteristic (ROC) curve to analyze the results.

RESULTS

The PREDIC index was applied to 302 drowning deaths and 624 children 0-4 years old living in Matlab. The results of t-test indicate that the drowned children had a statistically (t=-8.58, p=0.0001) significant higher mean PREDIC score (6.01) than those in comparison group (5.26). Drowning cases had a PREDIC score of 6 or more for 68% of the children however, the comparison group had 43% of the children with score of 6 or more which was statistically significant (t=-7.36, p<0.001). The area under the curve for the Receiver Operating Characteristic curve was 0.662.

CONCLUSION

Index score construction was scientifically plausible; and the index is relatively complete, fairly accurate, and practical. The risk index can help identify and target high risk children with drowning prevention programs. PREDIC index needs to be further tested for its accuracy, feasibility and effectiveness in drowning risk reduction in Bangladesh and other countries.

Childhood drowning and traditional rescue measures: case study from Matlab, Bangladesh

Recent mortality data indicate that approximately half a million people drown each year worldwide, with more than 97% of such deaths occurring in low-income and middle-income countries. The purpose of this study was to examine verbal autopsy data on the circumstances of childhood drowning in Matlab, Bangladesh. The study analysed 10 years (1996-2005) of data which reported 489 deaths in children under 5 years and recorded preimmersion, immersion and postimmersion events. The data summarised household characteristics, age, gender and time of drowning event. The study also examined traditional rescue methods performed on children who were removed from the water OR found drowning. Of 489 deaths, 57% were aged 1-2 years and had a drowning mortality rate of 521 per 100 000 children. Most drowning events occurred during the morning (68%), in ponds (69%), and while the mother was busy doing household chores (70%). Traditional rescue methods were attempted in 55% of children and the most frequently reported measure was to spin the child over head (35%). Only 3% of families tried to perform resuscitation. Verbal autopsy data for Matlab is a useful resource for childhood injury research in a low-income country. The study is one of the first to publish data on traditional rescue practices performed on drowning children in rural Bangladesh. The findings suggest that interventions should be designed using locally identified risk factors to reduce childhood drowning incidents. Community-based resuscitation techniques and emergency medical systems are needed to improve postimmersion recovery of the child.

Burden of fall injuries in Pakistan--analysis of the National Injury Survey of Pakistan

There are no reliable estimates of the burden of fall-related injuries in Pakistan. To assess this burden and develop an epidemiologic profile for these injuries data from the National injury Survey of Pakistan, a cross-sectional population-based survey on injuries, were analysed to determine incidence and relative risks for fall injury. The annual incidence of fall-related injuries was 8.85 per 1000 population per year (95% CI: 6.8-11.3). The mean and median age of individuals injured by falls was 19 years and 10.5 years respectively. Children under the age of 15 years were at a substantially higher risk of fall injuries. Being a student and farmer/labourer/vendorwere associated with a higher risk for falls compared with unemployed. Fall-related injuries are a health burden in Pakistan, especially in children under 15 years of age. This represents a significant loss of healthy life and requires policies to curb this burden in the population.

The burden of road traffic injuries in Nigeria: results of a population-based survey

BACKGROUND

Mortality from road traffic injuries in sub-Saharan Africa is among the highest in the world, yet data from the region are sparse. To date, no multi-site population-based survey on road traffic injuries has been reported from Nigeria, the most populated country in Africa.

OBJECTIVE

To explore the epidemiology of road traffic injury in Nigeria and provide data on the populations affected and risk factors for road traffic injury.

DESIGN

Data from a population-based survey using two-stage stratified cluster sampling. SUBJECTS/ SETTING: Road traffic injury status and demographic information were collected on 3082 respondents living in 553 households in seven of Nigeria's 37 states.

MAIN OUTCOME MEASURES

Incidence rates were estimated with confidence intervals based on a Poisson distribution; Poisson regression analysis was used to calculate relative risks for associated factors.

RESULTS

The overall road traffic injury rate was 41 per 1000 population (95% CI 34 to 49), and mortality from road traffic injuries was 1.6 per 1000 population (95% CI 0.5 to 3.8). Motorcycle crashes accounted for 54% of all road traffic injuries. The road traffic injury rates found for rural and urban respondents were not significantly different. Increased risk of injury was associated with male gender among those aged 18-44 years, with a relative risk of 2.96 when compared with women in the same age range (95% CI 1.72 to 5.09, p<0.001).

CONCLUSIONS

The road traffic injury rates found in this survey highlight a neglected public health problem in Nigeria. Simple extrapolations from this survey suggest that over 4 million people may be injured and as many as 200 000 potentially killed as the result of road traffic crashes annually in Nigeria. Appropriate interventions in both the health and transport sectors are needed to address this significant cause of morbidity and mortality in Nigeria.

Call for more research on injury from the developing world: results of a bibliometric analysis

BACKGROUND & OBJECTIVE

Injury prevention is a daunting health challenge as public health systems particularly in the developing world are least prepared to respond to this issue. In 2005, an estimated 5.4 million people worldwide died from injuries over 90 per cent in low- and middle-income countries. The main objective of this bibliometric analysis was to document injury literature published on low- and middle- income countries, and also to quantify literature on road traffic injuries by countries before and after the World Health Day on Road Safety celebrated in April 2004.

METHODS

A systematic search was done using MeSH terms on PubMed. Papers on road traffic injuries were assessed by country/cluster and by publication date for two periods (March 2001-March 2004) and (April 2004-April 2007). The rate of articles published per million population was calculated. Finally, a comparison was made between disease burden in disability adjusted life years (DALYs) and quantum of papers published. The search was performed on April 29, 2007.

RESULTS

PubMed had 8.26 million articles listed; of which, 72 per cent were in English and only 2 per cent were on unintentional injuries. For papers in all languages including English on road traffic injuries, 41 per cent were from US, 36 per cent from Europe (other than Eastern Europe). Two most populous countries, China and India contributed only 0.9 and 0.7 per cent papers on road traffic injuries, respectively. On neoplasm there were 280 articles published per million population whereas for road traffic injuries, rate was 4 articles per million population. Northern Africa, India and China had less than one article on road traffic injuries per 1,000 road traffic related deaths. The percentage change in English papers on road traffic injuries for the period 2004-2007 in comparison to period 2001-2004 was +191 per cent for China, +118 per cent for India, and +106 per cent for Middle East. Unintentional injuries overall represented 18 per cent of the burden in terms of DALYs and represented only 2 per cent of all published articles.

INTERPRETATION & CONCLUSION

The results noticeably reflected the small proportion of papers on injuries, the dominance of US, and the apparent increase in percentage of road traffic injuries papers from low- and middle- income countries after World Health Day on Road Safety in 2004. Policies on injury prevention and safety in developing countries will be effective if based on local evidence and research, and designed to suit the social, political, and economic circumstances found in developing countries.

Cost-effectiveness of traffic enforcement: case study from Uganda

BACKGROUND

In October 2004, the Ugandan Police department deployed enhanced traffic safety patrols on the four major roads to the capital Kampala.

OBJECTIVE

To assess the costs and potential effectiveness of increasing traffic enforcement in Uganda.

METHODS

Record review and key informant interviews were conducted at 10 police stations along the highways that were patrolled. Monthly data on traffic citations and casualties were reviewed for January 2001 to December 2005; time series (ARIMA) regression was used to assess for a statistically significant change in traffic deaths. Costs were computed from the perspective of the police department in $US 2005. Cost offsets from savings to the health sector were not included.

RESULTS

The annual cost of deploying the four squads of traffic patrols (20 officers, four vehicles, equipment, administration) is estimated at $72,000. Since deployment, the number of citations has increased substantially with a value of $327 311 annually. Monthly crash data pre- and post-intervention show a statistically significant 17% drop in road deaths after the intervention. The average cost-effectiveness of better road safety enforcement in Uganda is $603 per death averted or $27 per life year saved discounted at 3% (equivalent to 9% of Uganda's $300 GDP per capita).

CONCLUSION

The costs of traffic safety enforcement are low in comparison to the potential number of lives saved and revenue generated. Increasing enforcement of existing traffic safety norms can prove to be an extremely cost-effective public health intervention in low-income countries, even from a government perspective.

Road traffic injuries in urban Africa and Asia: a policy gap in child and adolescent health

OBJECTIVE

This study highlights the burden of urban road traffic injuries (RTIs) in children and young adults in South Asia and Sub-Saharan Africa to heighten awareness of current limitations in child health policies, and to direct future research and intervention development.

METHODS

Comparative analysis of recent Sub-Saharan Africa and South Asia reviews of RTIs, World Health Organization (WHO) Global Burden of Disease statistics, and the Bangladesh Health and Injury Survey.

PARTICIPANTS

Children aged 0-18 years in South Asia and Sub-Saharan Africa reviews, aged 0-14 years in the WHO data, and aged 1-17 years in the Bangladeshi data.

RESULTS

Child pedestrians comprise the largest proportion of urban RTI victims. More healthy life years were lost per 1000 children aged 0-18 years in South Asia than Sub-Saharan Africa. Disability-adjusted life years lost per 1000 children aged 0-14 years was greater in Africa than South-east Asia. South-east Asia has the greatest overall incidence of RTIs; however, Africa has poorer reported outcomes for children aged 0-14 years.

CONCLUSION

These data sources point to the salience of intervening in RTIs in children to prevent a predicted boom in the RTI burden in children, particularly in the poorest regions of the world. However, child health policies in these regions have not yet embraced RTI, either in research or programmes.