Ministry of Health REPORT: Evaluation of the Vietnam road traffic injury prevention project (VRTIPP)

Transcription

1 Ministry of Health World Health Organization Hanoi School of Public Health REPORT: Evaluation of the Vietnam road traffic injury prevention project (VRTIPP) Hanoi, December 2009

2 Research team Nguyen Trong Ha, MPH Pham Viet Cuong, PhD La Ngoc Quang, MD, MPH Du Hong Duc, BPH Nguyen Quang Vu, BPH Nguyen Y Van, BPH Department of Epidemiology, the Hanoi School of Public Health The Center for Injury Policy and Prevention Research, the Hanoi School of Public Health Department of Epidemiology, the Hanoi School of Public Health The Center for Injury Policy and Prevention Research, the Hanoi School of Public Health The Center for Injury Policy and Prevention Research, the Hanoi School of Public Health The Center for Injury Policy and Prevention Research, the Hanoi School of Public Health Acknowledgement We would like to thank WHO Viet Nam for their support. Many thanks also to all the agencies that agreed to be interviewed as part of this report. These include the Ministry of Health, hospital staff, police officers and restaurant owners in Yen Bai, Da Nang and Binh Duong. i

3 Content List of Abbreviations...v Executive summary...1 CHAPTER 1. INTRODUCTION Importance of the study Project summary Study objectives...10 CHAPTER 2. LITERATURE REVIEW Current status of traffic injuries in the world Current status of traffic injuries in Vietnam Current status of helmet wearing while riding motorcycles and traffic injuries Current situation of alcohol consumption during traffic and traffic injuries...13 CHAPTER 3. METHOD Location and time Study design Target population Data collection Data processing and analysis Ethical issues Limitations...22 CHAPTER 4. PROJECT ACTIVITIES Project provinces Project activities...24 CHAPTER 5. HOSPITAL AND POLICE DATA Results Hospital data Results Police data Discussion Hospital data Police data Conclusion and recommendation...43 CHAPTER 6. HELMET USE Results Household data Characteristics of the sample...45 ii

4 1.2. Knowledge on transport safety Knowledge on helmet use Impact of communication Impact of general IEC on helmet use Attitude on helmet use Practice of helmet use Practice of helmet use for children Measure to promote helmet use Results Xe-om driver data Characteristics of the sample Knowledge on transport safety Knowledge on helmet use Impact of communication Impact of general IEC on helmet use Attitude on helmet use Practice of helmet use Practice of helmet use for children Measure to promote helmet use Discussion Household data Xe-om driver data Conclusion and recommendation...65 CHAPTER 7. DRINK-DRIVE Results Household data Drinking behaviour Knowledge on drink-drive Impact of communication Attitude on drink-drive Practice of drink-drive Measure to promote compliance of drink-drive regulation Results Xe-om driver data Drinking behaviour Knowledge on drink-drive Impact of communication Attitude on drink-drive...79 iii

5 2.5. Practice of drink-drive Measure to promote compliance of drink-drive regulation Discussion Conclusion and recommendation...83 REFERENCES...85 iv

6 List of Abbreviations BL GDPMEH IEC FU KAP RTA TOT WHO Baseline General Dept. of Preventive Medicine and Environmental Health Information, Education and Communication Follow-up Knowledge, Attitude and Practice Road traffic accident Training of trainer World Health Organisation v

7 Executive summary Introduction Road traffic has become greater and greater concern in almost every country in the world, including developed and developing countries. It has been projected that traffic injuries in the world would rise from number 9 of fatality leading cause in 2004 to number 5 by In Viet Nam, rapid economic development and urbanization in recent years have led to a significant increase in the number of vehicles. As a result, the trend of road traffic injuries and mortality due to RTI has increased significantly. Since 2007, the World Health Organization (WHO) and the Ministry of Health with support from the Bloomberg Foundation have initiated the Vietnam Road Traffic Injury Prevention Project (VRTIPP) which focused on two currently burning issues including health wearing and drink driving. There have been a number of activities carried out during the implementation of the project in Yen Bai, Da Nang and Binh Duong in 2008 and This study is a component of the project to explore the changes from the baseline to the final stage of the project. Objectives 1. To evaluate outcomes of project activities. 2. To evaluate the overall results of the project concerning controlling and limiting traffic injuries and injuries in provinces of Yen Bai, Da Nang and Binh Duong compared to the findings of the baseline assessment in November Methodology Similar to the baseline survey, the study was implemented in 3 provinces: Yen Bai, Da Nang and Binh Duong from September, 2009 to October, The current study took the main core design which is a combination of quantitative and qualitative approaches. The quantitative component includes secondary data collection from hospital and police system and knowledge, attitudes and practices survey on helmet use and drink driving. Secondary data collection is used to aggregate data on road traffic injuries and injuries from hospital and police sources. A revised and updated data collection forms was created to adapt with project activities. Secondary data collection: data from hospital system includes the summary of road traffic injuries admitted to hospitals from December 2007 to May 2009; data from police system includes the summary of road traffic injuries from May 2008 to May Household survey on knowledge, attitudes and practices was conducted among household adult members and xe-om drivers. Qualitative components include a series of in-depth interviews with health officials, police officers and restaurant owners 1

8 Findings Project activities There were a number of components of activities to improve collection of data on road traffic accidents in hospital and police system, promotion of helmet use and road safety related to drink-drive. To improve collection of data on road traffic accidents (RTAs), the General Department of Preventive Medicine and Environmental Health (Ministry of Health) initiated a system to collect detailed information of all admission due to RTAs in 100 hospitals. The implementation of this activity have contributed to improvement on the reporting of helmet use, alcohol use and vehicles involved in the accidents in hospitals. There were a number of international and in country trainings and workshops with participation of project stakeholders. Experience from other countries on improving road safety was shared to project stakeholders. With increased awareness of project stakeholders on road traffic accidents would be an important factor to facilitate other activities during the implementation of the project. A number of activities toward promotion of helmet use including Information, Education and Communication (IEC) campaigns, distribution of helmets were organised in project provinces. These activities, along with the implementation of helmet regulation (Resolution 32, effective from December 15 th 2007) have contributed to significant improvement of helmet use in the population. IEC campaigns on promotion of road safety related to drink-drive, provision of equipments and training on using equipments were activities toward prevention of drink-drive. Activities in this component would contribute to the improvement in the reporting of alcohol use in hospital system, where the proportions of not recorded on alcohol use reduced significantly. More recently, the Ministry of Health has approved the protocol for testing of blood alcohol concentration of hospital admission due to RTAs. Hospital and police data Hospital data Binh Duong was the province with the largest number of hospital admissions due to RTA, 29,907 cases, followed by Da Nang with 20,535 cases and finally Yen Bai with 7,370 cases. In comparison between the baseline (2007) and follow-up (2009) data, there seems to be a large increase in the number of admissions in Yen Bai and Binh Duong, except Da Nang where the number of admissions slightly decreased. 2

9 Over time, Yen Bai was the province with the lowest rates and fluctuated slightly. While in Da Nang, the rates during the baseline were greater than those during the follow-up period, in Binh Duong, the rates during baseline were lower than those during the follow-up period. Toward the end of the follow-up period, the rates seem to be on increasing trend in both Da Nang and Binh Duong. In comparison to the baseline survey, the reporting of information related to means of transport helmet use and alcohol use has been considerably improved in hospitals. Police data During the period from June 2008 to May 2009, there were 372 RTAs reported in Yen Bai, 737 in Da Nang and 892 in Binh Duong. Over time, the rates of RTAs in Da Nang and Binh Duong seem to fluctuate at smaller extent than those in Yen Bai over time. Despite the fluctuation, in all three provinces, there seems to be a decreasing trend toward the end of the follow-up period. Regarding the data reporting issue, there has been significant improvement in the report of helmet use but not for the alcohol use. KAP on helmet use Household data Data were collected from respondents, among these 434 from Yen Bai, 403 from Da Nang and 406 from Binh Duong. Highest proportions are people aged years old and years old, 28.4% and 30.1% respectively. In the sample, 59.1% was male and 40.9% was female. Da Nang was the province with the highest driving license ownership (94.3%), followed by Binh Duong (92.9%) and Yen Bai was the one with lowest proportion (89.8%). Regarding the response to question on road safety, Compliance with road traffic regulation was the option chosen the most, almost 67%. More than 40% selected no accident. Wearing helmet when driving and no drink-drive was chosen by 21.5% and 15% of respondents. Most people were aware of the regulation of helmet use. More than 95% of respondents had correct response to the type of road user having to wear a helmet, with Da Nang being the province with highest proportion. More than 95% of respondents were also correct on the type of road requiring helmet use. There were almost 65% of respondents recalling that they had seen or heard at least one commercial promoting helmet use. Among these, in all three provinces, 3

10 television, newspaper, poster and billboard seems to be the most common channels of communication. Large proportion of respondents showed their agreement on the use of helmet. Moreover, there was also increasing trend of agreement on statements encouraging helmet use. In comparison between the baseline and follow-up results, this proportion increased from 97.8% to 98.3% in Da Nang and from 88% to 95.3% in Binh Duong. Among those who had driven during the previous week, 93% in Yen Bai, 97% in Da Nang and 98% in Binh Duong, who had always worn a helmet because, in their opinion that was for their own safety. However, there were still some (25% in Yen Bai, 21% in Da Nang and 23% in Binh Duong) reported that wearing a helmet was also to avoid being caught by police. Among those who had always made the kid wearing a helmet, 92% in Yen Bai, 99% in Da Nang and 99.6% in Binh Duong reported they wore a helmet for the kid because this was for the kid s safety. Xe-om driver data Data were collected from 266 xe-om drivers, among these 91 from Yen Bai, 91 from Da Nang and 84 from Binh Duong. Of this particular occupation, most of them were males and in this survey especially, all xe-om drivers were males. Highest proportions are people aged years old in all provinces. Regarding the response to question on road safety, Compliance with road traffic regulation was the option chosen the most in Da Nang (41%) and Binh Duong (77%). The option no accident was the most commonly chosen in Yen Bai (58%) and second most in Da Nang and Binh Duong. Wearing helmet when driving and no drink-drive was chosen by 11-44% and 8-35% of xe-om drivers. Most people are aware of the regulation of helmet use. The proportion knowing this regulation was highest in Da Nang (100%), followed by Binh Duong (98.8%) and lowest in Yen Bai (87.9%). The proportion of knowing the regulation increased in Da Nang and Binh Duong. Fisher exact test for the difference of the proportion in baseline and follow-up shows that it is statistically significant in Binh Duong (p < 0.05), but not significant in Da Nang (p = 0.18). On the other hand, the proportion of knowing the regulation decreased significantly in Yen Bai (p < 0.05). Overall, there were almost 50% of xe-om drivers recalling that they had seen or heard at least one commercial promoting helmet use. Among these, in all three provinces, television and poster seems to be the most common source of communication. More than 80% agreed that helmet can reduce the risk of head injury (Yen Bai: 88%; Da Nang: 80%; Binh Duong: 96%). Regarding the concern of wearing 4

11 helmet among children, majority of xe-om drivers showed their agreement on the necessity of wearing helmet among children. Among those who had driven during the previous week, 90% in Yen Bai, 86% in Da Nang and 99% in Binh Duong, who had always worn a helmet because, in their opinion that was for their own safety. However, there were still some (38% in Yen Bai, 32% in Da Nang and 29% in Binh Duong) reported that wearing a helmet was also to avoid being caught by police. Sixty-six percent of xe-om drivers in Yen Bai, 92% in Da Nang and 88% in Binh Duong had always made the kid wearing a helmet. Among those who had always made the kid wearing a helmet, 84% in Yen Bai, 80% in Da Nang and 98% in Binh Duong reported they wore a helmet for the kid because this was for the kid s safety. KAP on drink-drive Household data Regarding the knowledge on drink-drive regulation, there were more than 75% of respondents (79% in Yen Bai, 77% in Da Nang and 80% in Binh Duong) reported that they are aware of the regulation. However, going into more detail of the regulation, including the limit and the effective date of the regulation, the proportions of correct answer were very small. Only 4% in Yen Bai, almost 1% in Da Nang and also just 4% in Binh Duong could correctly state the alcohol limit. Regarding the effective date, only 2% of respondents in Yen Bai, 8% in Da Nang and 20% in Binh Duong, correctly reported. Less than 50% of respondents could recall any of the commercials on the issue of drink-drive. Similar to the source of information on helmet regulation, television was prominently the most common source of information, where more than 90% of respondents in Yen Bai and Binh Duong and almost 100% of respondents in Da Nang got to know about the commercial promoting road safety related to drink-drive. Don t drink then drive was the message chosen the most among respondents, 86% in Yen Bai, 78% in Da Nang and 93% in Binh Duong. The second most message that respondents could get was there are serious consequences for drink-drive, for you and your family, selected by 24% in Yen Bai, 44% in Da Nang and 62% in Binh Duong. Majority of respondents agreed with statements on the risk of accident or those to promote prevention of drink-drive and small percentage agreed with statements that promote drink-drive. For example, on the statement that driving after drinking alcohol will increase the risk of accident, 96% of respondents in Yen Bai, 97% in Da Nang and also 97% in Binh Duong agreed with this statement. 5

12 There were approximately 50% had ever driven after having several drinks, 51% in Yen Bai, 52% in Da Nang and 48% in Binh Duong. Almost 90% of respondents stated that it was because they were conscious enough to drive and around 20% stated that they had no other alternative to get home or work. Regarding the experience as a passenger, or sitting on a motorcycle that the driver just has had several drinks, 78% in Yen Bai, 5% in Da Nang and 48% in Binh Duong. The main reason was also that in their thinking, the driver had been conscious enough. More than 60% of respondents had that thinking. Xe-om driver data Regarding the knowledge on drink-drive regulation, very high proportion of xe-om drivers reported that they are aware of the regulation (87% in Yen Bai, 71% in Da Nang and 86% in Binh Duong). Going into more detail of the regulation, only 14% in Yen Bai and 0% in both Da Nang and Binh Duong could correctly answer the current alcohol limit. Only 6% of xe-om drivers in Yen Bai, 0% in both Da Nang and Binh Duong could correctly report the effective date. Binh Duong was the province with highest percentage of recalling any of the commercials promoting road safety related to drink-drive prevention, 51%, followed by Yen Bai, 44% and finally Da Nang, 39%. Television was prominently the most common source of information, where more than 90% of respondents in Yen Bai and Binh Duong, but only 54% in Da Nang. Don t drink then drive was the message chosen the most among xe-om drivers, 90% in Yen Bai, 97% in Da Nang and 95% in Binh Duong. The second most message that xe-om drivers could get was the risk of having a crash increases if you re over the limit, selected by 42% in Yen Bai, 0% in Da Nang and 46% in Binh Duong. Large proportion of xe-om drivers agreed with statements on the risk of accident or those to promote prevention of drink-drive. On the statement that driving after drinking alcohol will increase the risk of accident, 90% of xe-om drivers in Yen Bai, 80% in Da Nang and also 91% in Binh Duong agreed with this statement. About 60% had ever driven after having several drinks, 55% in Yen Bai, 82% in Da Nang and 56% in Binh Duong. Among these, almost 80% of xe-om drivers stated that it was because they were conscious enough to drive and around 20% stated that they had no other alternative to get home or work. Seventy percent in Yen Bai, 36% in Da Nang and 51% in Binh Duong had been as a passenger, or sitting on a motorcycle that the driver just has had several drinks. The main reason was also that in their thinking, the driver had been conscious enough. More than 70% of xe-om drivers had that thinking. 6

13 Recommendation Overall, the project has gained significant achievements on all aspects of the objectives. Data on road traffic accidents from both hospital and police systems have been improved in terms of quality and sufficiency. The practice of helmet use among general population and xe-om drives has increased significantly in comparison with the baseline. Regarding the issue of drink-drive, general public and xe-om drivers have had positive toward the prevention of drink-drive. However, their knowledge on the detail of the regulation is still limited. Despite, significant achievement, followings are recommendations for the project implementation. Data on road traffic accidents in hospital and police 1. There should be timely feedback mechanism to update and revise data collection protocol of hospital admission, so that the burden for hospital staff can be minimised and the quality of data collected can be optimised. 2. Training on the use of any new equipment should be well organised and supervised. Qualification test can be implemented by the end of the training to ensure proper use of the new equipment. 3. For the successful of the intervention, there should be mechanism to ensure simultaneous implementation of 3 E s including Education, Engineer and Enforcement. This is particularly true for the issue of drink-drive and alcohol use among victims admitted to hospital due to RTAs and among drivers on road. Education for the public on drink-drive seems to be done well. However, there were difficulties for the implementation of Enforcement due to the lack of equipment and skill to use. Helmet use 1. Strengthening the supervision of compliance with legal regulations, supervision activities and applying strictly fines to cases of violation. 2. There should be full materials to help traffic police to solve the practical situation of violations. 3. Further strengthening propaganda activities with multi-strategic approaches. Developing more communication elements of content and messages that give strong impressions on all walks of life. Further pushing up effective educational strategies to change people s attitudes toward helmet wearing. Assisting people to have clear benefit of wearing helmets when taking part in traffic can not only bring benefits to themselves but also to other people, especially children. 4. Developing more types of communication materials, innovating both their content and format so as to direct them at different target groups. 7

14 Drink-drive 1. The IEC activities should be implemented on synchronous basis with larger coverage and more systematically to target groups. 2. The content of IEC materials should be focused on the main elements: consequences of drink-drive, alcohol limit, scheme of fine if violating. 3. The language of IEC materials should be as simple as possible. A conversion of concentration in blood and in exhaled air is highly demanded. 4. IEC activities should continue with a number of different channels, especially on television and poster which were found to be the most common source of information. In addition, information on drink-drive readily available at the point of sale, such as restaurants, shops, bottle/can label. 5. Enforcement from the police force should be properly implemented with appropriate equipments and sufficient skill to use. 6. Guideline documents should be issued to provide instructions on implementing the new law on drink-drive. 7. There should be close coordination among levels of administration, sectors, branches and provinces to ensure the effectiveness of the drink-drive regulation in particular and of the road traffic law in general. 8

15 CHAPTER 1. INTRODUCTION 1. Importance of the study In recent years, the issue of traffic injuries and injuries has remained one of serious health concerns while efforts are being made in controlling and preventing them. Moreover, the trend continues to increase. It has been projected that traffic injuries in the world would rise from number 9 of fatality leading cause in 2004 to number 5 by [1] According to the estimation made by WHO in the Western Pacific region based the results of the project on global disease burden conducted in 2004, there were approximately cases of mortality due to traffic injuries in the same year. Of these cases, up to 93% took place in low and middle income countries, of which Vietnam is one. [2] The issue becomes more concerned when many of the fatal cases occurred to people in working age or those of great contribution to work force. It is also revealed by the WHO in the Western Pacific region that traffic injuries make up the greatest cause of death among the age groups of and years of age. [2] Therefore, the impacts, whether long or short-term, by traffic injuries are great to communities. Apart from the burden of disease and fatality, traffic injuries also cause great economic losses. On annual basis, around 1% of GNP of low-income countries, 1.5% of GNP in average-income countries and 2% of GNP in high-income countries turn out to be losses due to traffic injuries. These figures would be equivalent to 518 billion dollars in low-income countries, which is 65 billion dollars more than the money for development support that those countries would receive. One of the notable problems is that the data systems in low-income countries are very limited, thus leading to the fact that those figures can [1, 3] very well be much lower than the actual burdens. Strong socio-economic changes in Vietnam alongside with high pace of urbanization in Vietnam in recent years have entailed a rapidly increased number of means of transports. As a consequence, the number of cases of traffic injuries and fatality has always stayed high. When the total number of transport means in 1997 as estimated by the National Committee for Transport safety was only over 5 million, the most recent figure of registered means by July 2009 recorded by the same committee is over 28 million. Of these means, motorcycles made up a very high percentage, nearly 95% of the total vehicles. [4] The severity of current status of traffic injuries in Vietnam has pushed forward many measures to be taken aimed at better controlling the situation. One of the most remarkable events in relation to this effort is that the Resolution numbered 32 (NQ 32/2007/CP) was issued in June 2007, with regard to the implementation of a number of urgent solutions for controlling traffic injuries and conjunctions, which included the regulation on helmet wearing enforced on every one riding on motorcycles, which came into force on December 15 th [5] This can be seen as one of the right steps in the determination to reduce traffic injuries and injuries. It is revealed by the internationally aggregated data that wearing helmets while riding motorcycles can possibly reduce the risk of traffic fatality by 42% and the risk of head injuries by 69%. [6] Another remarkable event is that the National Assembly has passed the New Law on Road Transport (the Law numbered 23/2008/QH12) dated November 2008, which has new 9

16 regulations on alcohol consumption while driving. This regulation came into force on July 1 st To motorcycle riders, the permissible limit of alcohol concentration is not over 50 miligam/100 millilitres of blood, or 0.25 miligam/1 litre of exhaled air. For car drivers, they are not allowed to have alcohol in either bloodstreams or breaths. [7] 2. Project summary In his letter numbered 491/TTg-QHQT dated April 1 st 2008, the Prime Minister of Vietnam officially approved the project on Piloting initiatives on traffic safety in Vietnam funded by WHO from the Bloomberg Family Foundation s total non-revocable amount of USD, with partnership fund of (46,880USD) to be allocated to MOH annual budget as regulated by the state budgetary laws. The project on Piloting initiatives on traffic safety in Vietnam implemented measures to prevent traffic injuries, was aimed at reducing the rates of mortality and injuries, and included measures to raise levels of awareness and law compliance with regard to traffic rules; implementation of pilot models on helmet use and limiting alcohol consumption while driving. The project specific objectives include: 1) Contributing to raising people s awareness and law compliance with regard to helmet use and limiting alcohol consumption while taking part in traffic; 2) Contributing to limiting traffic injuries through the implementation of good practices in helmet wearing and alcohol limiting; and 3) sharing experience and practical lessons learnt nationally and internationally. The project was implemented in three provinces of Yen Bai, Da Nang and Binh Duong. The project had 5 components to ensure its successful implementation. Part 1 included initial evaluation of the current status of helmet wearing and alcohol consumption in the three project provinces for data collection (current status of helmet wearing, alcohol consumption, attitudes and conceptions of local people towards these issues and risk factors) to serve as foundation for project planning and indicators for effectiveness evaluation at the project completion. Part 2 included activities for raising awareness of the community as well as policy makers with regard to traffic injuries and their prevention. Part 3 included capacity building activities through training courses in the sectors of health, police traffic wardens, restaurant owners and high risk targets related to helmet wearing and alcohol consumption during traffic participation. Part 4 included project monitoring and evaluation activities. Part 5 included project management activities. 3. Study objectives 1. To evaluate outcomes of project activities. 2. To evaluate the overall results of the project concerning controlling and limiting traffic injuries and injuries in provinces of Yen Bai, Da Nang and Binh Duong. 10

17 CHAPTER 2. LITERATURE REVIEW 1. Current status of traffic injuries in the world On average, over 1.2 million cases of death and over 50 million traffic injuries are recorded annually. Of these cases, over 90% of fatality cases are found in low and middle income countries. [1] In the Western Pacific region alone, among the 37 countries and territories, fatality cases have been recorded and over 93% of them were found in low and middle in come countries in the region. [2] These low and middle income countries are suffering the greatest from traffic fatalities whilst the burdens of mortality, disability and economic losses due to traffic injuries mainly fall on them. It is estimated that by 2020, traffic injuries will become the second biggest cause of annual DALY losses. While traffic injuries tend to decrease in high-income countries, they continue to increase in low-and-middle-income countries. In South east Asia, the rate may possibly come up to 144% by 2020 in comparison with that in [3] 2. Current status of traffic injuries in Vietnam In Vietnam, the aggregated data on traffic safety collected during the first 7 months of 2009 show a positive change with regard to road traffic safety. During this time period, there occurred 961 traffic injuries and injuries where 902 people were killed and 565 people were wounded. Compared with figures of July 2008, the number of traffic injuries reduced by 71 cases (-6.88%), the number of traffic fatalities reduced by 21 cases (-2.28%) and the number of injured people reduced by 52 (-8.43%). Aggregately, during the first 7 months of 2009, there were 7,192 cases, in which 6,729 cases were fatalities and 4,540 were injuries. Compared with those figures of the same periods in 2008, the number of traffic injuries was reduced by 302 cases (-4.03%), number of fatalities reduced by 115 (-1.68%) and the number of injuries was reduced by 355 (- 7.25%). The rate of road injuries per transport means during the first 7 months of 2009 was 2.39 cases, 2.28 fatalities, and 1.54 injuries. In comparison with the same period of 2008, this rate was reduced by 0.17 cases, 0.14 fatalities and by 0.10 injured people. [4] This serious situation in Vietnam has pushed forward the implementation of many measures for better controlling the traffic injuries in the country. One of the most remarkable efforts was the introduction of the Resolution numbered 32 (NQ 32/2007/CP) issued in June 2007, concerning a number of urgent solutions aimed at controlling traffic injuries and congestions, among which was the regulation on helmet wearing enforced on people riding motorcycle, which came into force on December 15 th [5] Another remarkable event is that the National Assembly had passed the New Law on Road Transport (the Law numbered 23/2008/QH12) dated November 2008, which has new regulations on alcohol consumption while driving. This regulation came into force on July 1 st To motorcycle riders, the permissible limit of alcohol concentration is not over 50 miligam/100 millilitres of blood, or 0.25 miligam/1 litre of exhaled air. For car drivers, they are not allowed to have alcohol in either bloodstreams or breaths. [8] 11

18 In practice, compared with the data from the Ministry for Communication and Transports, which was mainly revealed by the police force, the realistic status in Vietnam is much higher. There are many limitations in this data system. In the first place, the tendency was to record only the severe cases, particularly cases of fatalities. Additionally, traffic police stations are often located in large cities and along national highways or inter-provincial highways, and as a result, many of cases occurring in rural areas or along smaller roads have not been recorded. 3. Current status of helmet wearing while riding motorcycles and traffic injuries 3.1. Research in the world Research studies conducted in other parts of the world such as the United States, Europe, Taiwan, Thailand and Indonesia show that, although it does not reduce the number of traffic injuries, the wearing of helmet while riding motorcycles can reduce considerably the consequences caused by traffic crashes, such as fatalities and serious head trauma. It can also reduce many of the costs for hospital admission, treatment and rehabilitation. [9-16] The data aggregated in the research studies conducted by Liu et al on the effectiveness of helmet wearing point out that it can reduce risks of fatality due to traffic injuries by 42% and reduce risks of head trauma by 69%.[6] In Taiwan, the 2004 study conducted by Shao-Hsun shows that helmet wearing can reduce risk of fatality due to traffic crashes by 40%, and reduce skull trauma and neck injuries by 53%. [13] In Ichikawa et al study on impacts of the regulation on helmet wearing while riding motorcycles in Thailand, the regulation enforced on motorcycle riders and their passengers was issued in 1994 and came into effect on January 1 st The enforcement of helmet wearing has contributed to reducing brain trauma by 41.4% and mortality rate by 20.8%. Head injuries, neck injuries and fatalities are caused in cases of not helmet wearing. [12] 3.2. Research in Vietnam Much has been done by specialists on traffic injuries and helmet wearing as this is a serious and common problem. Remarkably, a study was conducted by Hung et al to assess the situation of wearing helmets among motorcycle riders in Hai Duong, a Red River Delta province of Vietnam. The study was conducted in 2005, when there was a regulation on motorcycle riders wearing helmets on highways and provincial roads outside the city. The study shows that the proportion of riders wearing helmets only accounts for approximately 30%. Although there are financial fine schemes and the regulation on forceful wearing of helmets, the proportions of wearing helmets can only account for approximately 60% and about 40% respectively. The study also points out that the behaviour of wearing helmets can be better only at road segments where the helmet wearing regulation is applicable and where there is presence of traffic police wardens. [11] It was only after the new regulation on all people riding motorcycles in traffic was enforced that the proportion of wearing helmets could be increased considerably. The observations made on the activities of helmet wearing among the population in Yen Bai, Da Nang and Binh Duong, the 12

19 three provinces under the project of Piloting initiatives on traffic safety show that the rates of helmet wearing are all very high compared with the period before the enforcement of the regulation. Compared with the first made observation in November 2007, when the new regulation was not yet enforced, the highest rate of helmet wearing in Yen Bai province was only 65%, followed by 60% in Binh Duong and the lowest was in Da Nang, 41%. [17] However, during the next observations made in June 2008, the respective rates all rose up to 94% in Yen Bai and Binh Duong and around 100% in Da Nang. During the following observations made in December 2008 and May 2009, the rates remained above 90% in project provinces, although there were certain changes. Notably, the rate of helmet wearing in Da Nang was constantly over 99%. [18-20] 3.3. Regulations on helmet wearing in Vietnam The first regulation on helmet wearing was issued on the basis of the circulars by the Ministry for Communication and Transports, including the circular numbered 312/2000/TT-BGTVT and the circular numbered 08/2001/TT-BGTVT, respectively in 2000 and Of these circulars, the circular 312/2000/TT-BGTVT specified that the helmet wearing regulation would come into effect on January 1 st However, the helmet wearing was only enforced when motorcycle riders drive on highways and provincial highways outside towns, townships, provincial cities and outside the inner cities of cities under direct government management. Helmet wearing inside inner cities and on other roads was encouraged. [21] Regarding the circular 08/2001/TT-BGTVT, the helmet wearing is enforced on those riding motorcycles or mopeds, (including children), on the road system of Vietnam (including highways, inter-provincial, district, communal roads, urban path ways and specialized ways). However, this circular additionally and clearly pointed out that fines are applied to cases of violations, failures to wear helmets on national highways, provincial highways outside the area of inner cities. Motorcycle riders without helmets found in inner cities would only be given reminders and would not be fined. [22] In 2007, on June 29 th, the Government of Vietnam issued the Decision on a number of urgent solutions to be taken to control traffic injuries and congestions. At item 6, point b, it is stipulated that helmet wearing is enforced on all types of roads and ways. [23] This is a remarkable change in comparison with the previous regulations in that this is the first time when helmet wearing is enforced on all types of roads and ways and fining is applied to all kinds of violations, regardless of different types of roads where violations are found. 4. Current situation of alcohol consumption during traffic and traffic injuries 4.1. Research studies in the world Alcohol consumption has different influences. Moderate consumption can help enhance health conditions of users. However, irrational usage can lead to users suffering from impacts on health, social and mental conditions. Increased risks of traffic injuries are one typical consequence caused by irrational consumption of alcoholic beverage. In their reports on alcohol abuse in Vietnam published in 2006, the authors from the National Institute for Health Strategies 13

20 and Policies aggregated many research studies to describe traffic injuries under the influence of alcohol. In France, in 1999, alcoholic beverage was related to 40% of injuries and injuries and 4000 mortality cases due to traffic injuries. In the United States, in 2002, up to 41% of the fatality cases due to traffic injuries were caused by motorists under the influence of alcoholic beverage. In New Zealand, this percentage was 25%. Furthermore, in Thailand, the rate of fatality related to alcoholic drinking was up to 62%. [24] In the book entitled Alcohol usage and motorists: A material on road safety for decision and practice makers published in 2007 by the World Health organization in Bangalore India, 28% of traffic crashes among males of over 15 years of age was related to alcoholism. In Sunsai and Dharari, Nepal, 28% of motorists consumed alcohol beverage; up to 17% of the total number of traffic crashes were due to alcoholic drinking. In South Africa, approximately 26 31% motorists suffering from non-fatal traffic crashes were found to have alcohol concentration over the permissible limit in their blood streams (0,08 g/100 ml). [25] 4.2. Research studies in Vietnam The reports by the authors from the National Institute for Health Strategies and policies also collected findings on the situation of alcoholism and driving. The collected data of the National Committee for Traffic Safety show that around 6% of all traffic injuries were related to alcohol beverages. However, the estimated data given by the National Committee for Traffic Safety are found to be much lower than the actual practice. The study conducted in Bac Lieu in 2005 shows that up to 24.5% of the traffic injuries occurring in the whole province were due to motorists having used alcoholic beverage. The data given by the General Department for Road and Railway Traffic collected in 3 years ( ) show that motorcycle riders account for the highest percentage of motorists consuming alcoholic beverage, 71%. [24] 4.3. Regulation on controlling alcoholic beverage in Vietnam Like many other countries in the world, Vietnam also has specific laws and policies to control alcohol consumption. As aggregated from reports by authors from the national Institute for Health Strategies and Policies, alcohol beverages are listed among products to be levied with special consumption taxes, VAT and import taxes. The level of special taxation fluctuates from 15 75%, depending on types of products (brandy or beer) and alcohol concentration. The Ministry of Commerce, now the Ministry of Trade and Commerce, also has a regulation that alcohol beverages are products that are limited in business transactions. Its transaction and consumption is under the control of the state. Business on alcohol beverages is also limited by banning its sale with automatic vendors; alcohol beverages are not allowed for sale in such public places as hospitals, schools, offices, railway stations and coach stations... Besides, the government ordinance numbered 150/2005/Nð-CP does not permit any sale of alcoholic drinks to children and adolescents (<16 years of age). The acts of advertising on and supporting alcoholic beverages are also limited. In relation to traffic safety, article 8 of the rules of road traffic has stated that it is prohibited that drivers of means of transports are under influence of high alcoholic concentration that exceeds the level of 80 mg/100 ml blood or 40 mg/1 litre of 14

21 exhaled air, regulated on monetary fines from 1 million to 2 million VND on motorists who have used alcoholic drinks with the alcoholic concentration in bloodstreams or exhaled air exceeding the regulated limit. [24] Most recently, the national Assembly has officially passed the law on communication and transports 2008, in which it is referred to the permissible limit of alcoholic concentration in bloodstreams and exhaled air of drivers of transport means. This law came into force on July 1 st However, in spite of the fact that there have been no official reports, there are still some limitations regarding the implementation of this new law. Typically, there is a lack of sub law documents to guide the implementation, a lack of supportive instruments for identifying alcoholic concentration, and inadequacy of traffic wardens knowledge and skills in tool usages. This leads to the possibility of occurring violations. Recently, a remarkable event is that the National Assembly has passed the New Law on Road Transport (the Law numbered 23/2008/QH12) dated November 2008, which has new regulations on alcohol consumption while driving. This regulation came into force on July 1 st To motorcycle riders, the permissible limit of alcohol concentration is not over 50 miligam/100 millilitres of blood, or 0.25 miligam/1 litre of exhaled air. For car drivers, they are not allowed to have alcohol in either bloodstreams or breaths. [7] 15

22 CHAPTER 3. METHOD 1. Location and time 1.1. Study location Similar to the baseline survey, the study was implemented in three provinces: Yen Bai, Da Nang and Binh Duong Time study The field work was conducted September, 2009 to October, 2009, including road traffic accident information based on secondary data in hospital and police records; a household survey on knowledge, attitudes and practices related to helmet and alcohol use; and an in-depth interview of health officers, police officers and restaurant owners. Data processing, analysis and report writing took place from November, Study design Taking the approach used in the baseline survey, the current study takes the main core design which is a combination of quantitative and qualitative approaches. The quantitative component includes secondary data collection from hospital and police system and knowledge, attitudes and practices survey. Secondary data collection is used to aggregate data on road traffic injuries and injuries from hospital and police sources. A revised and updated data collection forms was created to adapt with project activities. Secondary data collection: data from hospital system includes the summary of road traffic injuries admitted to hospitals from December 2007 to May 2009; data from police system includes the summary of road traffic injuries from December 2007 to May Household survey on knowledge, attitudes and practices was conducted among household adult members and xe-om drivers. Qualitative components include a series of in-depth interviews with health officers, police officers and restaurant owners 3. Target population The target populations for this survey include household members and xe-om drivers 1 Household members must be at least 18 years old and be able to ride a motorcycle. The sample size for household members was computed using the simple random sampling formula: 1 Xe-om driver is the person who controls the motorcycle to provide taxi service. 16

23 p q d 2 n = Z1 α / % + n: required sample size. + Z 1-α/2 : Z score that gives a confidence interval of 95% + p: the anticipated population proportion of helmet use or alcohol consumption. According to a recent study conducted by Hung, D.V et. al., the average helmet use rate is 30%. [11] The proportion of alcohol consumption (at least once per week) is approximate 34%, according to Institute of Health strategy and policy study. [24] In the formula, the value of 34% rate is used, since this results in a larger sample size. + q = 1 p + d: absolute precision = 5% represents a 10% addition to sample size required for subjects who are unwilling to participate or whom we are unable to contact: n = % The required sample size in each province is 380, rounding-up to 400. Since there might be a possibility of similar response of different members within the same household, in order to best represent the general population, only one member was selected from each visited household. Therefore, the calculated sample size is also the number of households to be visited in the actual survey. The total number of households in all 3 provinces was In each province, households were selected by multi-stage cluster sampling. In the first stage, two districts were randomly selected from the list of districts within the provinces. In each selected district, two random communes were selected. In each selected commune, 5 villages (in rural area) or living areas (in urban areas) were randomly selected. The sample size was equally distributed among these villages/living areas. Finally, a cluster of 20 adjacent households was selected in each village/living area. 17

24 Figure Sampling scheme of general population/household member in each province PROVINCE Random District Random District Random Comm. Random Comm. Random Comm. Random Comm. 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs 20 HHs The quantitative survey also used xe-om drivers as study subjects. This casual occupation provides taxi service by motorcycle. By the nature of their occupation, they would be expected to be at very high risk of road traffic injuries. A convenience sample of 90 drivers was selected in each province. Currently, there is no policy on management and control of xe-om drivers. They usually wait for clients in crowded areas with potential customers, such as the street corners, in front of schools or hospitals. A snow-ball sampling scheme was applied for this group. The surveyor approached and administered the questionnaire to xe-om drivers. Once finish the questionnaire, the surveyor asked that xe-om drivers to refer to his other colleagues. The surveyor continued the process until interviewing 90 xe-om drivers. 18

25 Figure Sampling scheme (snow-ball) for xe-om drivers First xe-om driver Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om Xe-om 4. Data collection 4.1. Road traffic accident information based on hospital and police databases Hospital databases: Collection form used with hospital databases is designed and pre-tested to collect information about hospitalized victims of road traffic injuries. The collection information include number of hospitalized patients by + age group (< 18, 18-59, 60+ years old) + gender (male, females) + body location of injury (head/face/neck, limbs, body, multiple, unknown) + vehicles involved (motorcycle or other) + helmet use (yes, no, not reported) and + alcohol use status (yes, no, not reported). Hospital staffs extracted from hospital records of the emergency department, where all emergency cases, including road traffic injuries come and then are transferred to specialized departments. Police databases: Collection police databases form was designed and pre-tested to include information on road traffic accident + number of crashes, 19

26 + number of fatality + number of injuries + number of vehicles involved (motorcycle or other) + number of helmet use (yes, no, not reported) and + number of alcohol use status (yes, no, not reported). Similar to data collected from hospital systems, police officers extracted from police records to fill in the pre-designed form. For most road traffic injuries, particularly serious one, police officers come to the scene and record the details of the injuries. Sometimes, police officers can also have the information about an accident when victims come to the station and report about the accident Quantitative cross-sectional survey Questionnaire from the baseline survey was revised and updated with new information such as statement of risk of neck injury due to wearing a helmet, and questions on IEC materials and opinion on IEC messages. Information collected included: + Basic demographic variables: gender, occupation, date of birth, education, ethnicity, years of riding motorcycles, current frequency of using motorcycle, average distance ridden per day, possession of a driving license. + Knowledge on traffic safety: meaning of traffic safety, causes of road traffic injuries, measures to prevent road traffic injuries + Attitude on helmet use: opinion on various statement about using helmets + Practice of helmet use: self estimate on current helmet use among general population, current helmet use as a driver, reasons for wearing/not wearing a helmet as a driver, current helmet use as a passenger, reasons of wearing/not wearing a helmet as a passenger, ways to promote helmet use, features of helmet quality and correct helmet wearing. + Acceptance of new helmet regulation: knowledge of previous helmet regulation and new helmet regulation; sources of information about helmet regulation, necessity of the regulation, opinion about compliance with the regulation among the general population, opinion on how to enforce the regulation. + Opinions on IEC materials and messages on helmet wearing and drink drive prevention + Alcohol consumption: frequency of consumption during the last month, the average consumption per day during the last month, drinking behaviour (time of day, day of the week, common drinking place), experience of drunk driving as driver and passenger. + Acceptance of (possible) regulation on alcohol control: opinion on the acceptable level of alcohol to drive, necessity of regulation on alcohol control and reasons, opinion about compliance with the regulation among the general population and themselves, opinion on how to promote compliance. 20