Toward safety promotion among road users : Epidemiology and prevention of road traffic injuries in Iran

Sammanfattning: Road traffic injuries (RTIs) are a major public health problem. Iran has one of the highest RTI mortality and morbidity rates in the world. This thesis aims to contribute understandings on fatal road-user patterns and characteristics as well as RTI numbers and rates, and to explore stakeholders perceptions both on barriers to - and facilitators of road-user safety and on prevention of this problem in the Iranian region. Quantitative and qualitative methods have been combined to explore road traffic injury phenomena. This thesis includes a cross sectional study (Paper I) and employs the capture-recapture method (Paper II), and grounded theory method (Paper III and Paper IV). Data for the first two studies were collected between March 2004 and March 2005 in the West Azarbaijan Province (WAP) of Iran and data for the third qualitative study were collected between March and December 2007 in both WAP and on the national level. Paper I describes the pattern of fatal RTIs and crash circumstances in WAP. The majority (85%) of the deceased were men. Females were mainly killed as either car passenger or pedestrians. Close to two-thirds of victims were rescued by untrained people and nearly four out of five were taken to hospital by passenger car rather than by ambulance. Paper II presents two register-based studies estimating the number and rate of fatal RTIs in WAP employing the capture-recapture method. The Death Registration System (DRS) and Forensic Medicine System (FMS) had recorded 669 and 665 fatalities respectively (roughly 22 fatal RTIs per 100 000 inhabitants). The capturerecapture method estimated 1 018 deaths (34 per 100 000). Overall, the DRS and the FMS ascertained 65% of the estimated number of fatal RTIs. In Paper III, the aim was to study pre-crash possibilities for prevention of RTIs and the core variable was identified as lack of system approach to road-user safety . Related barriers were identified: human factors; lack of safety in the transportation system; and lack of organizational coordination. Suggestions for improvement included education, more effective legislation, more rigorous law enforcement, improved engineering in road infrastructure, and an integrated organization to supervise and coordinate preventive activities. Focusing on post-crash management in Paper IV, the major barriers were identified as: involvement of laypeople; lack of coordination; inadequate pre-hospital services; and shortcomings in infrastructure. Suggestions for laypeople included: 1) a public education campaign in first aid, the role of the emergency services and cooperation of the public at the crash site, and 2) target-group training for professional drivers, police officers and volunteers involved at the crash scene. In conclusion the pattern of fatal RTIs in WAP differs somewhat from similar low- and middle-income countries. More attention should be paid to vulnerable road-users; young people, the over-65s and those living in rural areas. The burden of fatal road traffic injury in WAP is 1.53 times higher than records in the current data sources suggest. The lack of a system approach to road-user safety was the most important concern in the stakeholder study. There is a need for both a major change in stakeholders attitudes to road-user safety and an integrated system to lead and coordinate all RTI prevention activities.