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4 Analysis of the Causal Factors of Morbidity and Mortality from Roadway Crashes in Al-Ain, United Arab Emirates Dr. Mohammed El-Sadig, Roadway Transportation and Traffic Safety Research Centre Dept. of Community Medicine, Faculty of Medicine & Health Sciences, U.A.E. University, Al-Ain, P.O. Box: 17666, U.A.E., Dr. Suleiman Ashur, Department of Civil and Environmental Engineering, College of Engineering, U.A.E. University, Al-Ain, P.O. Box Dr. Yasser E. Hawas, Department of Civil and Environmental Engineering, College of Engineering, U.A.E. University, Al-Ain, P.O. Box ABSTRACT Background and Methodology: High rates of serious road traffic accidents (RTAs) have been reported in the UAE in recent years. The research aims to determine the morbidity and mortality from motor vehicle crashes in Al-Ain, UAE and to highlight the impact of the problem on school safety. Data sources were Al- RTTSRC - 3

5 Ain Traffic Police reports on RTA deaths and injuries, during Jan-Dec Results: The analysis showed that out of total MVCs which took place in Al-Ain district during 2005, rollovers constituted 21% of MVCs, side angle collisions 17% and collisions with fixed objects were 15.3%. Most traumatic crashes (24%) were at residential areas, 23% at highways and 21% at the commercial center. Minor injuries were 15.9%, moderate were 60.5%, serious were 10% and fatal injuries were 13%. 71% of casualties were attended by MoH or Police Ambulance. Reported seatbelt use among casualties was 2.8%. Sudden diversion, inexperience and tire failures were the main RTA causes reported by Police. Most crashes (51.7%) occurred between 6.00 a.m. and noon, while 27% occurred between midnight and 6.00 a.m. The mean casualties age was 31 years; and mostly males (97%). Local (UAE) casualties were 39% followed by Pakistanis (20%) and Indians (10%). Conclusions: The results confirm the status of MVCs as the main cause of premature death, injury and disability in the UAE. More active intervention and enforcement are needed to control the problem. 1. Introduction Roadway traffic operation is accomplished by a continuous sequence of decisions by individual road users. This takes place within the determinants of a complex system of roadway engineering, environmental hazards and traffic control of different types of vehicles, small and large, heavy and light. These three determinants take varying responsibility in accident and injury causation (1). However, it is evident that a fourth determinant -the road user- bears the major responsibility (2). The population of road users includes individuals who have consumed alcohol or medication, who lack concentration and calm judgment, who are in a desperate hurry, or who are experiencing an unexpected physical or medical difficulty. It is equally important to remember that the quality of the operation of roadway traffic is not based on these personal attributes only. Many other factors, including law and social norms and perceptions influence the behavior of road users. Therefore, despite the efforts of traffic safety engineers, legislators, health authorities and municipal authorities to facilitate the flow of safe roadway traffic, some people at some times disregard traffic lights, evade police RTTSRC - 4

6 surveillance, drive while in an inappropriate physical or mental state, take unreasonable chances, or engage in similar deliberately risky behaviors that lead to motor vehicle crashes (MVCs) (3,4). These failures do exist, in spite of any conceivable measures, which could be imagined. The intermingling of these four determinants dictates the necessity to investigate their in-depth causal impact on motor vehicle crash occurrence, in order to identify the most likely control measures to improve safety on the roads. 2. Background to the Problem of MVCs in the UAE The World Health Organization (WHO) recently revealed that, globally, nearly three million deaths were occurring each year from injury, poisoning and burns throughout the last decade; over two million of these were in developing countries (5). Moreover, it showed that, worldwide, up to one third of all hospital admissions resulted from injuries and almost 60% of these were due to MVCs (5). The WHO and the World Bank (WB) have estimated that in the 1990s road accidents constituted the ninth cause of death or disability; out of total of over a hundred separately identifiable causes of death or disability (6). By the year 2020, they are forecasted to move up to second place in terms of years of life lost, third place in terms of disability adjusted life-years (DALY s) and sixth place as a cause of death (6). Such admissions are costly because of the demands implicated on health services for emergency, diagnostic and therapeutic care, rehabilitation and lifelong assistance to achieve optimal social functioning. According to the data, the annual economic costs of injuries, lost productivity of workers and medical and social costs were estimated to exceed US$ 500 billion worldwide (5). To this cost must be added the social and psychological costs of permanently disabling conditions for the injured individuals and their families. The literature reviewed, relating to the problem in the United Arab Emirates (UAE) and the Gulf, has shown that the crude rates of road traffic accident (RTA) fatalities and injuries were much higher in those countries than in most developed countries (1). Among the Gulf countries, the UAE s MVC fatality rate is still higher compared to Saudi Arabia (20.6/100,000), Qatar (15.8/100,000), Oman (28/100,000) or Kuwait (15.7/100,000) (5). However, while the overall trend of RTA fatalities and injuries in the UAE has been declining in recent years, the trends of injury severity were constantly RTTSRC - 5

7 worsening (7). However, despite the scale of road-traffic injury severity in the UAE and the other neighboring Gulf countries little has been done to control this problem. 3. Objectives and Methodology: The study aim was to determine the risk of morbidity and mortality in MVCs in Al-Ain District - UAE, during the year 2005; and to investigate the most likely causal factors of these crashes. In addition, the study attempted to determine the safety measures that could be introduced and implemented for preventive purposes. Descriptive and analytical methods of MVC epidemiology were used to quantify the risk of injury and death in MVCs and to analyze the causal factors of the problem in Al-Ain district, UAE. Al-Ain constitutes the second largest district in the emirate of Abu Dhabi, with a current population of around half million. The district consists of Al-Ain City and three towns: Mazayed, Swaihan and Al-Wagan which are located at the Eastern side, Western and the Southern side of the district, respectively. The city of Al-Ain is the fourth largest city in the UAE with a population of around 350,000. It is located around 160 km East of Abu Dhabi City, the Capital of the UAE and about 150 km south of Dubai, the commercial capital of the UAE. Descriptive and analytical methods of epidemiology were used to quantify the risk of motor vehicle (MV) injury and death on roadway crashes and to analyze the causes and mechanisms of the problem in Al-Ain, UAE. The causal factors investigated included drivers behaviors, environmental factors and a number of other risk factors. To ensure a high quality data and reduce the data entry error, the complete records of a data sample of 541 injury MVCs was obtained from Al-Ain Police Department. These records represent 90% of the complete census of MVC injuries and fatalities according to Al-Ain Traffic Police records for the year Data entry and analysis were performed using the statistical software package (SPSS version 13) and the graphs were prepared using Microsoft Excel The Chi-square test was used to ascertain the association between two or more categorical variables, (p less or equal to 0.05 was considered as the cut-off value for significance). 4. Results of the Analysis RTTSRC - 6

8 The study sample consisted of 541 different roadway crashes reported by Al-Ain Traffic Police which represent 90% the total number of injury MVCs that took place in Al-Ain district during the period from January to December The descriptive analysis of the total sample revealed that 60% of MVCs were reported and/or took place at Al-Ain traffic police (Al-Ain central traffic zone), 12% were reported and/or took place on the road to Abu Dhabi (Al-Saad traffic zone), 8% were reported and/or took place on the road to Dubai (Al-Hayer traffic zone), 8% at Mazayed, 6% at Swaihan and 6% at Al-Wagan. The majority of road users (drivers, passengers and pedestrians) involved in MVCs (59.2%) (95% C.I: ) were years old, 18% (95% C.I: ) were years old, 14% (95% C.I: ) were 46 years old or above and 8% (95% C.I: ) were at school age of 18 years or less (Fig. 1). Most of the road users involved in Al-Ain district (40.2%) (95% C.I: ) were UAE citizens followed by Asians (35%) (95% C.I: ), 11.4% (95% C.I: ) were Arabs of other nationalities, 6% (95% C.I: ) were GCC citizens and 7.3% were other nationalities (Fig. 2). The majority of road users involved were males (96%) (95% C.I: ) and 4% only were females. Sixty two percent (95% C.I: ) of the casualties involved completed primary education, 21% (95% C.I: ) completed intermediate education, 9% (95% C.I: ) completed university education and 8% (95% C.I: ) were illiterate. Table (1) Distribution of MVC Casualties in Al-Ain UAE during 2005 by Age Group Motor Vehicle Injury Severity Age group Minor Moderate Serious Fatal Total 0-18 years % 52.0% 6.1% 6.1% 100.0% 27.6% 16.6% 11.3% 9.0% 17.7% years % 57.2% 10.1% 12.4% 100.0% 56.7% 66.1% 67.9% 65.7% 64.1% years % 52.9% 10.6% 17.6% 100.0% 12.6% 14.7% 17.0% 22.4% 15.3% RTTSRC - 7

9 60 years > % 50.0% 12.5% 12.5% 100.0% 3.1% 2.6% 3.8% 3.0% 2.9% Total % 55.4% 9.6% 12.1% 100.0% Fig. (1) Distribution of MV Casualties by Age > 60 years 2% years 15% <= 18 years 10% years 21% years 52% Fig. (2) Distribution of MVC Casualties by Nationality Others 7% Asians 35% UAE 41% Other Arabs 11% GCC 6% Of the total sample, 45% (95% C.I: ) of MVCs took place during the weekend. Most of MV crashes (50%) (95% C.I: ) took place during the morning hours ( noon), 28% (95% C.I: ) at late night or early morning hours RTTSRC - 8

10 ( a.m.), 15% (95% C.I: ) in the afternoon hours and 7% (95% C.I: ) only between the evening and midnight ( ). The descriptive analysis of the lighting conditions when MV crashes occurred showed that most of them (59%) took place during the day time, 30% during the evening or in poor lighting conditions and 12% at night. The majority of MVCs (96%) took place in clear weather conditions, 3% at rainy conditions and less than one percent during dusty or foggy conditions. Most of injury MVCs in Al-Ain (89%) took place on dry road surface, 3% on wet road surface, 4% on dusty roads and 3% on unpaved roads. Sixty nine percent of the total MVCs took place on the road (freeways, arterials and collector roads), 14% at traffic signals, 6% at stop signals and 8% at give-way signs or lines. The descriptive analysis of the vehicles involved in MVCs in Al-Ain district during 2005 revealed that 50% of these vehicles were older than 5 years. Fifty seven percent of them were equipped with two axels, 33% had no axels and 8% had 3 axels. Forty six percent (95% C.I: ) of the vehicles involved had shaded glass. Of the total vehicles involved 41% sustained severe damages, 33% sustained moderate damages, 16% minor damages and 11.2% sustained no damages. The analysis of injury severity (according to police records) in MVCs, showed that 59% (95% C.I: ) of the casualties involved sustained moderate injury, 16% (95% C.I: ) sustained minor injury, 12% (95% C.I: ) sustained serious injury and 13.4% (95% C.I: ) sustained fatal injury (Fig. 3). Of the total casualties involved 65% (95% C.I: ) were drivers, 17% (95% C.I: ) were passengers and 18.3% (95% C.I: ) were pedestrians. Of the total number of casualties 2.2% only were reportedly using the seatbelt when the crash occurred. Of the total sample, 98% of MV drivers involved were unchecked for drug or alcohol use. Fig. (3) RTTSRC - 9

11 Distribution of MV Injury by Injury Severity Serious 12% Fatal 13% Minor 16% Moderate 59% Of the total number of motor vehicle crashes 68% caused injury or death for at least one occupant, 16% caused injury to two occupants, 7.4% to three occupants and 9% to four occupants or more. Sixty one percent of the occupants who sustained injury or death were traveling in the first case vehicle, 22% were in the second case vehicle and 17% were in the third or other case vehicle. Of the total casualties involved in MVCs in Al-Ain district, 71% (95% C.I: ) were taken to hospital by police or hospital ambulance, 21% (95% C.I: ) were taken by civilian vehicles and 6% (95% C.I: ) only were transported by regular police patrol cars. The analysis of the sample population by types of MVCs showed that 22% (95% C.I: ) of injury MVCs in Al-Ain during 2005 were due to rollover collisions, 20% (95% C.I: ) were pedestrian collisions, 16% (95% C.I: ) were collisions with a stationery object, 16% (95% C.I: ) were side angle collisions, 14% (95% C.I: ) were rear impact collisions, 4% were head-on collisions, 4% were collisions at roundabouts and 1% only were collisions with animals. The analysis of the causal factors, described by police following MVCs, revealed that 29% (95% C.I: ) were for sudden diversion or failure to stick to the driving lane, 9% (95% C.I: ) were for failure to leave enough space or tailgating, 5% (95% C.I: ) for breaking the red signal, 5% (95% C.I: ) for inexperience or absence of RTTSRC - 10

12 driving license, 5% (95% C.I: ) for failure to give pedestrians priority, 5% (95% C.I: ) for tire burse and/or critical road conditions, 4% for entering the road when the traffic was unclear, 3% for driving under alcohol or drugs, 3% for excessive speed and 19% for unspecified reasons. The analysis of MV injury severity by driver nationality revealed that 46% of the total number of drivers who sustained fatal injuries were UAE citizens, 35% were Asians and 14% were from other Arabian nationalities. UAE nationals also sustained the highest proportions of serious injury (35%), moderate injury (40.2% and minor injury (38%) compared to other nationalities but the results were not statistically significant (p=0.798). The analysis of MV injury severity by road user age revealed that 42% of road users who sustained fatal MV injuries were 29 years, 37% were years old and 21% aged 46 years (Fig.4). Likewise, 48% of serious MV injuries, 51% of moderate MV injuries and 53% of minor injuries were sustained by road users aged 29 years. However, the results were of border statistical significance (p=0.07). The analysis of MV injury severity by crash time showed that most of fatal MVCs either occurred between noon (44%) or between midnight and a.m. (33%). Similarly, 83% of serious injuries, 77% of moderate injuries and 81% of minor injuries occurred during the same time interval, although the association was not statistically significant (p=0.895). Fig. (4) Distribution of MV Injury Severity by Drivers Nationality RTTSRC - 11

13 The analysis of MV injury severity by vehicle type revealed a highly statistically significant association between injury severity and type of vehicles (p=0.002). MVCs involving motor vehicles type 4WDs were statistically significantly associated with causing higher injury severity to both occupants and/or road users (p=0.002). Of the total MVC injuries sustained by occupants using 4WDs, 30% were fatal injuries compared to 11% only to occupants of saloon cars (p=0.002). The analysis of MVC injury severity by the type of the middle road barrier revealed no statistically significant association between injury severity and the existence or absence of middle road barriers (p=0.296). However, the analysis showed that 61% of fatal injuries took place on roads that had no middle barrier, compared to 14% only on roads with steel or concrete barriers. The analysis of MV injury severity by road user status revealed that 64% were MV drivers, 17% were passengers and 19% were pedestrians. The analysis revealed a borderline statistically significant association between injury severity and road user status (p=0.065). As expected, pedestrians had increasingly higher MVC injury severity compared to passengers and drivers (p=0.065). For example, of the total sample 19% of pedestrians sustained fatal injuries, compared to 12.7% of total drivers and 9.2% of passengers (p=0.065). RTTSRC - 12

14 The analysis of MV injury severity by mode of transportation to hospital revealed no statistically significant association between the mode of transportation and injury severity outcomes (p=0.248). Likewise, no statistically significant association was found between motor vehicle glass shading and the level of MVC injury severity (p=0.358). The analysis of MVC injury severity, as reported by police, and seatbelt use revealed a highly statistically significant association between injury severity and failure to use the seatbelt (p=0.007). Of the total sample, 21% of occupants not using the seatbelt sustained fatal injury compared to 0% of drivers using the seatbelt (p=0.007). The analysis of MVC injury severity reported by police by the likely personal-causal factors revealed no statistically significant association between injury severity and drivers personal causal factors (p=0.441). However, the results showed that drivers incompetence (e.g. failure to leave space, or to stick to lane, or to give way to road users or to give pedestrians priority, etc.) was responsible for 28% of traumatic MV crashes. Drivers violations to traffic regulations such as breaking the red signal or excessive speed were found responsible for 46% of MV crashes and 26% were for vehicle malfunctioning or environmental weather conditions. The analysis of MVC injury severity by type of crash revealed a statistically significant association between injury severity and type of crash (p=0.04). Pedestrian and roll over MV collisions had the highest injury severity compared to side impact, frontal, rear and animal collisions (p=0.04). For example, of the total fatal injuries 29% were for (frontal, rear and animal collisions), 28% were for pedestrian collisions, 15% for side impact collisions and 28% for rollover collisions. 5. Conclusions and Recommendations The study confirmed the status of MVCs, as a major and increasing concern for the health of the community in Al-Ain district and the UAE. Despite its huge investment in traffic RTTSRC - 13

15 infrastructure, the paradoxical increasing lethal outcomes of MVCs are clearly demonstrated. There is obviously a need to elucidate more precisely the underlying factors of these outcomes. However, based on the results of this study a key area for reducing fatality on the roads would be in the active enforcement of seat-belt legislation in the UAE roads. The recent estimates reported for seatbelt compliance by occupants in the UAE were 29% for expatriates and only 10% for UAE locals (8). It is established that the enforcement of the seatbelt, child restraints and helmet wearing could reduce motor vehicle injury by 40-70% (9). Another area of immediate concern would be to investigate the effectiveness of traffic safety measures, which have been introduced over the previous years, especially, measures enforcing speed controls on highways. For example, frequent police reports in the UAE suggest that the use of fixed positions for speed radar on UAE highways and the possibility of a wide spread use of radar detectors, that warn speedy drivers of the presence of mobile radar cameras, might have reduced the likelihood of spotting violating drivers, therefore, leading to persistent increase in the lethality of MVCs in the UAE. Therefore, it is important to impose primary measures to control speed through road design (i.e., setting up and enforcing well researched speed limits, traffic calming measures and to install more speed cameras to control violators). Traffic safety campaigns, targeting young drivers and the public, are equally needed to educate and enlighten the public about protective and safe driving skills, especially the importance of abiding with the correct and safe driving speed to avoid accidents that is in addition to the observance of streets for violators through active police patrolling. A third area of immediate concern is the high level of pedestrians deaths and injuries reported in the study. The annual UAE traffic police reports further reveal a persistent increase in the rates of pedestrian crashes on the UAE roads over the last few years. Therefore, immediate efforts are required to further elucidate the locations and clusters of these crashes in order to introduce the necessary measures that help controlling or reducing the problem such as low speed limits, light controlled crossing facilities, humps and safety barriers. Efforts are also needed to educate the community, especially the motorists about the importance of protecting the children, the elderly, the disabled and bicyclists in the neighborhoods, school zones, shopping malls, mosques, playgrounds and parking areas through abiding with posted speed limits at these areas. That is together RTTSRC - 14

16 with educating pedestrians and bicyclists about the necessity of paying attention and obeying traffic rules organizing street crossing and the importance of crossing streets from crosswalk points or at intersections. A fourth area of intervention will be the immediate management of casualties at the roadside and during transportation to hospital. The study showed a reasonable improvement in the proportion of casualties reached, transported and handled by ambulance in Al-Ain UAE. However, the analysis revealed that the levels injury severity sustained by those victims were not significantly different than injuries sustained by those handled and/or transported using other means. It is therefore a priority that the levels of trauma sustained by victims, together with the efficiency with which they have been managed, should be analyzed. Acknowledgement The authors sincerely acknowledge the support of the Research Affairs of the UAE University for allowing the resources to achieve this project. Our special thanks to the staff at Al-Ain Traffic Police Department for their invaluable support, effort and contribution to collect the data. Our thanks and appreciation also extends to the staff at the Roadway Transportation and Traffic Safety Research Center (RTTSRC) of the UAE University for their efforts to process the data and implement the study. 6. References 1) El-Sadig M; N. Norman, O. Lloyd, A. Bener, A. McGillivray and P. Romilly. Road Traffic Accidents in the United Arab Emirates: Trends of Morbidity and Mortality during Accidents Analysis & Prevention; Volume 35 :(4), ) Robertson L. Reducing Death on the Road: The Effects of minimum safety Standards, Publicized Crash test, Seat Belts, and Alcohol. American Journal of Public Health 1996; 86: RTTSRC - 15

17 3) Andersson R, Menckel E. On the Prevention of Accidents and Injuries: A Comparative Analysis of Conceptual Frameworks. Accidents Analysis and Prevention, 1995; 27: ) Andersson R. A Injury Causation, Injury Prevention and Safety Promotion Definitions and related analytical frameworks. In: L. Laflamme, L. Svanstrom, L. Schelp (Eds). Safety Promotion Research. Kristianstads Boktryckeri AB Publishers. Edition 500, ) World Health Organization (WHO) Report on Traffic Safety (2004). 6) Murray, C.J. and Lopez, Alan D Evidence-Based Health Policy---Lessons from the Global Burden of Disease Study, Science 1 November 1996: ) El-Sadig M, Alam MS, Carter AO, Fares K, Al-Taneuiji H, Romilly P, Norman JN, Lloyd O. (2004). The Effectiveness of the Seatbelt Legislation in the UAE. Journal of Accidents Analysis and Prevention. 36: ) Al-Husani Y, El-Sadig M. (2006). Seatbelt Compliance Among Motor Vehicle Occupants in the UAE Population: an Intervention study. (Under review). 9) Peden, M., Scurfield, R., Sleet, D., Mohan, D., Hyder, A. A., Jarawan, E., Mathers, C. The WHO Report on Road Traffic Injury Prevention (2004). RTTSRC - 16