Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
Contents lists available at SciVerse ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
Seatbelt use and speeding on three major roads in Egypt: a brief report Connie Hoe*a, Prasanthi Puvanachandraa, M. Hafizur Rahmana, Hesham El Sayedb, Soad Eldawyc, Ayman El-Dabaad, Mourid Albertd, Adnan A. Hydera a
Johns Hopkins University International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA Suez Canal University, Ismailia, Egypt c Central Agency for Public Mobilization and Statistics, Egypt d Ministry of Interior, Egypt b
KEYWORDS
ABSTRACT
Road safety Egypt Seatbelt use Speeding
Objective: Road traffic injuries pose a significant threat to the Egyptian population. Recent estimates revealed that Egypt experiences 42 road traffic deaths per 100,000 population (1.8% of all deaths in the country), which is the highest death rate in the region. More than half of the road traffic crashes that resulted in injuries occurred on the country’s highways. Despite the significance of this public health problem, very little risk factor information currently exists. The overall goal of this paper is to understand the burden of speeding and the level of seatbelt and child restraint use on a highway (Cairo Ring Road) and two urban roads crossing Alexandria city (Kornish and Gamal Abd-Elnaser roads). Methods: Two rounds of seatbelt and child restraint observational studies and one round of speed observational study were carried out between 2011 and 2012. Results: Findings revealed that seatbelt use among drivers and front seat passengers were low for all three sites (range: 11.1% to 19.8% for drivers; 2.9% to 4.0% for front seat passengers). Similarly, child restraint use in cars with children was very low ranging from 1.1% to 3.9% on all three roads. All three roads experienced a high percentage of vehicles driving above the speed limit (39.4% on Kornish Road, 22.6% on Cairo Ring Road, 11.8% on Gamal Abd Elnaser Road), with the majority of these vehicles driving 1 to 10 kilometer above the speed limit. Conclusion: Future interventions need to focus on enhancing enforcement of speed and seatbelt wearing, closing gaps in legislation, and standardizing existing data systems to help inform good road safety policies. © 2013 Elsevier Ltd. All rights reserved.
Introduction Road traffic injuries (RTIs) are the eighth leading cause of global mortality; contributing to 1.3 million lives lost each year.1 According to the 2010 Global Burden of Disease Study, this is a 46% increase from 1990. Modeled projections show that if nothing is done to address this growing problem, RTIs will continue to “rise in rank” to become the fifth leading cause of global mortality by 2030 (3.6% of all deaths).2 In addition to being a major contributor to global deaths, road traffic crashes also account for 20 to 50 million non-fatal injuries worldwide.3 Correspondingly, RTIs were ranked as the 10th leading cause of global disability-adjusted life years (DALYs) lost in 2010.1 Although RTIs occur in all regions of the world, low-andmiddle-income-countries (LMICs) suffer a disproportionate burden. These countries experience 90% of all the world’s road deaths despite having only 48% of the world’s registered vehicles.3 * Corresponding author at: Johns Hopkins University, International Injury Research Unit, 615 N. Wolfe St. Baltimore, MD, USA. Tel.: 215 531 2006 E-mail address: [email protected] (C. Hoe). 0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
In the World Health Organization (WHO) Eastern Mediterranean Region (EMR), for example, RTIs were ranked as the sixth leading cause of death in 2004 surpassing tuberculosis, malaria and HIV/ AIDS. Of all RTI related deaths in EMR (146,000), 95.2% were found in the low-and-middle-income countries of the region. Likewise, it is estimated that LMICs and high-income countries (HICs) in EMR lost 4,840,000 and 282,000 DALYs respectively.2 Data from 2010 also shows RTIs as the fourth leading cause of mortality in North Africa and Middle East as compared to being the 24th leading cause in Western Europe.1 In January 2010, Bloomberg Philanthropies funded the Global Road Safety Programme with the goal of reducing road traffic related deaths and non-fatal injuries in LMICs.4 Egypt, a middleincome country located within the WHO EMR, was one of the 10 countries selected. Egypt experiences 42 road traffic deaths per 100,000 population (1.8% of all deaths in the country), which is the highest death rate in the region.2 Data also revealed that there were 22,793 road traffic crashes in 2009 and 106,886 transport injuries (140.2 per 100,000 population) in 2010.5,6 More than half of the road traffic crashes that resulted in injuries occurred on the country’s highways.7
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C. Hoe et al. / Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
Figure 1. Percent of Seatbelt Use by Roads, Egypt, 2011-2012.
Currently, there is a dearth of information pertaining to risk factors for RTIs in Egypt, as coverage of the existing data systems is limited.8 The overall goal of this study was to measure the prevalence of selected risk factors for road safety in Egypt. The specific objectives were 1) to report seatbelt and child restraint use amongst drivers and passengers on the Cairo Ring Road and the Kornish Road and Gamal Abd Elnaser Road in Alexandria in 2011 and 2012, and 2) to report the prevalence of speeding on the Cairo Ring Road, and Kornish and Gamal Abd Elnaser Road, Alexandria in 2012. To our knowledge, this is among the first of such attempts in the country and will hopefully help guide policies and interventions in Egypt.
were accompanied by police officers during all observation days as per national rules. Data were entered and cleaned on-site and further cleaned and analyzed once transferred to JH-IIRU. Descriptive statistics were calculated to attain the baseline for the risk factors in the selected sites. The percentages of seatbelt use for drivers and front seat passengers were calculated for each round. Similarly, the percentages of vehicles driving above the speed were also tabulated. All analyses were conducted using STATA Statistical software (version 11) (StataCorp LP, College Station, TX). The study was deemed not human subjects research by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health (JHSPH).
Methods Results Primary data collection was carried out by JH-IIRU and CAPMAS with help from the WHO Egypt Country Office and the Ministry of Interior (MoI) on a highway (Cairo Ring road), and two urban roads crossing Alexandria city (Kornish and Gamal Abd Elnaser roads). Two rounds of seatbelt and child restraint observational studies and one round of speed observational studies were conducted. The two rounds of observational studies were carried out in June 2011 and March 2012 on Cairo Ring Road and October 2011 and March 2012 on the two roads in Alexandria governorate. Our research team used sampling frames provided by the Ministry of Interior (MOI) to randomly select four observation points for each road. This resulted in a total of 12 observation points for all three sites. A standardized observation protocol and data collection sheet were utilized to record speed, seatbelt, and child restraint use at the selected locations. All observers were trained staff in research methodology as well as in research ethics. For seatbelt and child restraint observations, the observers were divided into two teams of two for each road. Each team observed two sites twice a week (once during the weekday and once during the weekend) and each site was observed from 9:00 in the morning to 5:30 in the afternoon for four twohour periods. Only front-seat occupants (drivers and front seat passengers) were observed. For speed observations, observers used two moving radars for each road. The observation days and times were the same as that for the seatbelt study. All teams
Seatbelt and Child Restraint Use The total sample sizes for the two rounds of seatbelt and child restraint observational studies were 39,635 for Cairo Ring Road (Round 1: 17,643 and Round 2: 21,992 ), 40,167 for Kornish Road (Round 1: 18,978 and Round 2: 21,189), and 59,088 for Gamal Abd Elnasar Road (Round 1: 27,922 and Round 2: 31,166). The overall percentage of seatbelt use remained steady during the two observation cycles (Figure 1). On Cairo Ring Road, for example, findings from the first (10.9%) and second (11.1%) rounds were similar. Seatbelt use for drivers on all three roads was below 20% and ranged from 11.1% to 19.8% during the two observation cycles. As compared to the two other roads, the percentage of seatbelt use among drivers on Kornish Road was slightly higher for both rounds (18.5% and 19.8% respectively). As compared to drivers, the percentages of seatbelt use among front seat passengers were substantially lower for all three sites (less than or equal to 4.0%). When disaggregated by vehicle type, seatbelt use was much higher among private personal car drivers as compared to other types of vehicles (Table 1). This holds true for both rounds of observations and for all three roads except for taxi drivers on Cairo Ring Road. In contrast to the two roads in Alexandria governorate, the percentage of seatbelt use among taxi drivers on Cairo Ring Road is substantially higher and almost similar to the percentage of seatbelt use among private car drivers (range: 20.0% to 28.4%).
C. Hoe et al. / Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
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Table 1 Seatbelt Use Among Drivers by Vehicle Type and Roads, Egypt, 2011-2012 Private Cars
Taxis
Light Trucks
Large Trucks
Buses
Microbuses
Cairo Ring Road 2011 2012
28.4% (n=2,023) 31.8% (n=2,166)
20.0% (n=317) 28.4% (n=464)
5.3% (n=148) 9.5% (n=328)
6.8% (n=214) 7.4% (n=306)
6.4% (n=57) 6.5% (n=151)
2.6% (n=54) 3.3% (n=121)
Alexandria’s Kornish Road 2011 2012
25.6% (n=3,275) 26.1% (n=3,847)
5.3% (n=176) 8.9% (n=315)
2.1% (n=8) 1.5% (n=8)
2.6% (n=3) 4.7% (n=6)
3.1% (n=9) 1.0% (n=4)
2.2% (n=45) 0.9% (n=16)
Alexandria’s Gamal Abd Elnaser Road 2011 2012
25.9% (n=3,222) 20.4% (n=2,788)
6.1% (n=511) 5.8% (n=597)
3.3% (n=42) 3.2% (n=40)
3.0% (n=7) 2.3% (n=6)
0.9% (n=7) 0.7% (n=4)
0.9% (n=42) 0.3% (n=16)
Table 2 Seatbelt and Child Restraint Use Among Drivers in Cars with Children, Egypt, 2011-2012 % of seatbelt use among drivers in cars with children
% of children sitting in the front seat
% of children sitting in the front seat and wearing seatbelt
% of children sitting in child seat
Cairo Ring Road 2011 2012
21.8% (n=1,912) 17.2% (n=2,564)
40.6% (n=1,915) 42.2% (n=2,564)
7.6% (n=778) 10.0% (n=1,081)
1.9% (n=1,910) 3.9% (n=2,564)
Alexandria’s Kornish Road 2011 2012
22.2% (n=2,600) 17.4% (n=3,415)
36.5% (n=2,784) 33.1% (n=3,447)
3.2% (n=1,011) 3.0% (n=1,142)
2.8% (2,782) 3.0% (n=3,445)
Alexandria’s Gamal Abd Elnasar Road 2011 2012
17.1% (n=3,404) 5.7% (n=4,291)
40.9% (n=3,407) 41.4% (n=4,293)
12.2% (n=1,392) 4.8% (n=1,775)
1.4% (3,407) 1.1% (n=4,293)
A larger proportion of drivers in cars with child occupants use seatbelts as compared to drivers in cars without child occupants (Table 2). This holds true for both rounds of observations on Cairo Ring Road (21.8% and 17.2% as compared to 15.9% and 16.1%), the first round of observations on Kornish Road (22.2% as compared to 18.5%), and the first round of observations on Gamal Abd Elnasar Road (17.1% as compared to 13.7%). With regards to child occupants, a large proportion was found to be sitting in the front seat of the vehicle. This finding was consistent across all three roads and for both rounds of observations (range: 33.1% to 42.2%). Only 3.0% to 12.2% of these front seat child occupants wore seatbelts. The percentage of children sitting in child seats was also low (1.1% to 3.9%) on all three roads (Table 2). Speed Figure 2. Percent of Vehicles Driving Above Speed Limit by Road, Egypt, 2011.
The total sample sizes were 13,705 for Cairo Ring Road, 26,498 for Kornish Road, and 20,199 for Gamal Abd Elnasar Road. Findings showed that of the three roads, Kornish Road had the highest overall percentage of vehicles driving above the speed limit (39.4%; n = 26,498). Whereas 22.6% (n = 13,705) and 11.8% (n = 20,199) of drivers on Cairo Ring Road and Gamal Abd Elnaser Road exceeded the speed limit, respectively (Figure 2). When disaggregated by number of kilometers above the speed limit, the majority of the vehicles that exceeded the speed limit on all three roads drove 1 to 10 kilometer above the speed limit (Figure 2). For Cairo Ring Road, 47.5% of large trucks and 44.4% of microbuses exceeded the speed limit as compared to 5.4% of taxis. On Kornish Road, buses tended to speed most (52.3%) and trucks tended to speed less (light trucks: 20.3% and large trucks: 20.4%). On Gamal Abd Elnaser Road, the percentage of vehicles exceeding the speed limit was less than 12% across all types of vehicles except for buses, where 20% of the drivers drove above the limit (Table 3). When disaggregated by time of day, results showed that the percent of vehicles exceeding the speed limit on
Cairo Ring Road was consistent throughout the day (Range: 20.7% to 24.2%). This is also true for Gamal Abd Elnaser Road (Range: 10.1% to 14.1%). Kornish Road, on the other hand, experienced a higher percentage of vehicles speeding in the mornings; more than half of the vehicles were observed to be speeding during 9 am to 11 am, and around 40% were observed to have exceeded the speed limit during the 11 am to 1 pm time period. Discussion Road traffic injuries are a major public health problem in Egypt and efforts to address major risk factors such as increasing seatbelt and child restraint use, as well as managing speed are critically important. Results from this study revealed that that seatbelt usage was low on all three roads during two observation cycles; this is consistent with existing studies in this area.9 Similar to regional trends, our findings also showed that, when disaggregated by the type of front seat occupants, the percentage
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C. Hoe et al. / Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
Table 3 Percent of Vehicles Driving Above the Speed Limit by Vehicle Type, Egypt 2011
Cairo Ring Road Alexandria’s Kornish Road Alexandria’s Gamal Abd Elnaser Road
Private Cars
Taxis
Light Trucks
Large Trucks
Buses
Microbuses
26.8% (n=6126) 40.0% (n=18,646) 12.0% (n=14,515)
5.4% (n=3,069) 37.9% (n=894) 9.9% (n=1,249)
25.0% (n=2,819) 20.3% (n=158) 11.7% (n=94)
47.5% (n=522) 20.4% (n=944) 8.0% (n=587)
28.7% (n=1,160) 52.3% (n=3,472) 20.0% (n=1,464)
44.4% (n=4) 25.1% (n=2,384) 7.2% (n=2,290)
Speed limits: Cairo Ring Road: 90 kilometer/hour for private cars and taxis, 70 kilometer/hour for microbuses and trucks (light and large), and 80 kilometer/hour for buses; Alexandria’s Kornish and Gamal Abd Elnaser: 60 kilometers/hour for all types of vehicles.
of seatbelt use was substantially lower for front seat passengers as compared to drivers. One of the factors that may explain such low seatbelt usage in the country is the level of enforcement. According to the 2013 Global Status Report on Road Safety, seatbelt enforcement in Egypt was rated a “5” on a scale of 10 revealing that there is room for improvement.3 Our study also showed that child restraint use was very low for all selected sites and about two-fifths of the child occupants were found to be sitting in the front seat of the car. These results could be explained by the fact that, similar to other countries in the region, Egypt currently lacks a child restraint law.10 Although the enactment of such a law does not guarantee 100% coverage, it is likely to increase the percentage of child restraint use, particularly if paired with strong enforcement. A systematic review conducted by Zaza et al in 2001, for example, revealed that child restraint laws not only increases child safety seat usage but also decreases non-fatal and fatal injuries.11 Attention will need to be focused on changing current practice of allowing children to travel unrestrained in the front seat of passenger cars. The burden of speeding is also high in Egypt; among all roads, Kornish Road in Alexandria governorate had the highest percentage of vehicles exceeding the speed limit (39%). A literature review conducted by Puvanachandra et al in 2012 showed that academic studies pertaining to speed in Egypt currently do not exist.8 As with seatbelt use, one of the factors that may explain speeding is the level of enforcement. According to the 2013 Global Status Report on Road Safety, speed enforcement was also rated a “4” on a scale of 10.3 This study had several limitations. First, due to the political situation of the country, we were only able to conduct two rounds of observations for seatbelt and child restraint use and one round of observations for speed. While the results were generally consistent between the two rounds for seatbelt and child restraint use. More rounds are needed for a reliable baseline. Second, we were only able to observe two risks factors on three national highways and at specific times of day (9 am to 5:30 pm). Although findings did provide some insight about the issue, they are not nationally representative. Finally, the three sites were roads rather than populations, hence the individuals who drive on these roads may not necessarily be from these respective governorates of Cairo and Alexandria. Thus, these results are also not representative of these cities. As Egypt continues through its phases of political transitions, we hope that efforts towards road safety will be prominent. In 2012, Puvanachandra et al highlighted the steady improvements of the country’s data system; it is critical that such momentum is ensured in the future. Future interventions also need to focus on enhancing enforcement, standardizing existing data systems, and closing gaps in legislation such that child occupants are mandated to wear child restraints.
Conflict of interest All authors declare no conflict of interest. Acknowledgements This work was conducted as part of the Global Road Safety Programme in Egypt, funded by Bloomberg Philanthropies. We would like to thank Central Agency for Public Mobilization and Statistics, Ministry of Interior, Ministry of Health, World Health Organization Country Office and Eastern Mediterranean Regional Office, Global Road Safety Partnership as well as Association for Safe International Road Travel for their cooperation in the project. Authors’ contributions All authors have made substantial contributions. PP and AAH developed the study design. CH, PP, HR, HS, SE, AE, MA oversaw data collection; CH led the data analysis and prepared the manuscript. All authors reviewed the final version of the manuscript. References 1.
Institute for Health Metrics and Evaluation. Global Burden of Diseases, Injuries, and Risk Factors Study 2010. http://www.healthmetricsandevaluation.org/ gbd/research/project/global-burden-diseases-injuries-and-risk-factorsstudy-2010. 2. World Health Organization. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. 3. World Health Organization. Global status report on road safety: time for action. Geneva: World Health Organization; 2013. 4. Hyder AA, Allen KA, Di Pietro G, Adriazola CA, Sobel R, Larson K, et al. Addressing the implementation gap in global road safety: exploring features of an effective response and introducing a 10-country program. Am J Public Health 2012;102:1061-7. 5. Central Agency for Public Motorization and Statistics. Annual Statistics Report. Cairo, Egypt: CAPMAS; 2009. 6. Ministry of Health Egypt, World Health Organization. Injury Surveillance Report 2010. Cairo, Egypt: Ministry of Health Egypt Prevention Health Sector, Occupational Health Department, Injury Control Unit; 2010. 7. World Health Organization Regional Office for the Eastern Mediterranean. About Road Traffic Injuries. Geneva: WHO; 2009. 8. Puvanachandra P, Hoe C, El-Sayed F, Saad R, Al-Gasseer N, Bakr M, et al. Road Traffic Injuries and Data Systems in Egypt: Addressing the Challenges. Traffic Inj Prev 2012;13(Suppl 1):44-56. 9. Rady M. Behavioral Risk Factors Among Physicians. J Egypt Public Health Ass 1997;72; 233-56. 10. Soori H, Hussain SJ, Razzak JA. Road safety in the Eastern Mediterranean Region – findings from the Global Road Safety Status Report. EMHJ 2011;17:770-6. 11. Zaza S, Sleet D, Thompson R., Sosin D, Bolen J. The Task Force on Community Preventive Services. Am J Prev Med 2001;21(Suppl 4):31-47.
Contents lists available at SciVerse ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
Seatbelt use and speeding on three major roads in Egypt: a brief report Connie Hoe*a, Prasanthi Puvanachandraa, M. Hafizur Rahmana, Hesham El Sayedb, Soad Eldawyc, Ayman El-Dabaad, Mourid Albertd, Adnan A. Hydera a
Johns Hopkins University International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA Suez Canal University, Ismailia, Egypt c Central Agency for Public Mobilization and Statistics, Egypt d Ministry of Interior, Egypt b
KEYWORDS
ABSTRACT
Road safety Egypt Seatbelt use Speeding
Objective: Road traffic injuries pose a significant threat to the Egyptian population. Recent estimates revealed that Egypt experiences 42 road traffic deaths per 100,000 population (1.8% of all deaths in the country), which is the highest death rate in the region. More than half of the road traffic crashes that resulted in injuries occurred on the country’s highways. Despite the significance of this public health problem, very little risk factor information currently exists. The overall goal of this paper is to understand the burden of speeding and the level of seatbelt and child restraint use on a highway (Cairo Ring Road) and two urban roads crossing Alexandria city (Kornish and Gamal Abd-Elnaser roads). Methods: Two rounds of seatbelt and child restraint observational studies and one round of speed observational study were carried out between 2011 and 2012. Results: Findings revealed that seatbelt use among drivers and front seat passengers were low for all three sites (range: 11.1% to 19.8% for drivers; 2.9% to 4.0% for front seat passengers). Similarly, child restraint use in cars with children was very low ranging from 1.1% to 3.9% on all three roads. All three roads experienced a high percentage of vehicles driving above the speed limit (39.4% on Kornish Road, 22.6% on Cairo Ring Road, 11.8% on Gamal Abd Elnaser Road), with the majority of these vehicles driving 1 to 10 kilometer above the speed limit. Conclusion: Future interventions need to focus on enhancing enforcement of speed and seatbelt wearing, closing gaps in legislation, and standardizing existing data systems to help inform good road safety policies. © 2013 Elsevier Ltd. All rights reserved.
Introduction Road traffic injuries (RTIs) are the eighth leading cause of global mortality; contributing to 1.3 million lives lost each year.1 According to the 2010 Global Burden of Disease Study, this is a 46% increase from 1990. Modeled projections show that if nothing is done to address this growing problem, RTIs will continue to “rise in rank” to become the fifth leading cause of global mortality by 2030 (3.6% of all deaths).2 In addition to being a major contributor to global deaths, road traffic crashes also account for 20 to 50 million non-fatal injuries worldwide.3 Correspondingly, RTIs were ranked as the 10th leading cause of global disability-adjusted life years (DALYs) lost in 2010.1 Although RTIs occur in all regions of the world, low-andmiddle-income-countries (LMICs) suffer a disproportionate burden. These countries experience 90% of all the world’s road deaths despite having only 48% of the world’s registered vehicles.3 * Corresponding author at: Johns Hopkins University, International Injury Research Unit, 615 N. Wolfe St. Baltimore, MD, USA. Tel.: 215 531 2006 E-mail address: [email protected] (C. Hoe). 0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
In the World Health Organization (WHO) Eastern Mediterranean Region (EMR), for example, RTIs were ranked as the sixth leading cause of death in 2004 surpassing tuberculosis, malaria and HIV/ AIDS. Of all RTI related deaths in EMR (146,000), 95.2% were found in the low-and-middle-income countries of the region. Likewise, it is estimated that LMICs and high-income countries (HICs) in EMR lost 4,840,000 and 282,000 DALYs respectively.2 Data from 2010 also shows RTIs as the fourth leading cause of mortality in North Africa and Middle East as compared to being the 24th leading cause in Western Europe.1 In January 2010, Bloomberg Philanthropies funded the Global Road Safety Programme with the goal of reducing road traffic related deaths and non-fatal injuries in LMICs.4 Egypt, a middleincome country located within the WHO EMR, was one of the 10 countries selected. Egypt experiences 42 road traffic deaths per 100,000 population (1.8% of all deaths in the country), which is the highest death rate in the region.2 Data also revealed that there were 22,793 road traffic crashes in 2009 and 106,886 transport injuries (140.2 per 100,000 population) in 2010.5,6 More than half of the road traffic crashes that resulted in injuries occurred on the country’s highways.7
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C. Hoe et al. / Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
Figure 1. Percent of Seatbelt Use by Roads, Egypt, 2011-2012.
Currently, there is a dearth of information pertaining to risk factors for RTIs in Egypt, as coverage of the existing data systems is limited.8 The overall goal of this study was to measure the prevalence of selected risk factors for road safety in Egypt. The specific objectives were 1) to report seatbelt and child restraint use amongst drivers and passengers on the Cairo Ring Road and the Kornish Road and Gamal Abd Elnaser Road in Alexandria in 2011 and 2012, and 2) to report the prevalence of speeding on the Cairo Ring Road, and Kornish and Gamal Abd Elnaser Road, Alexandria in 2012. To our knowledge, this is among the first of such attempts in the country and will hopefully help guide policies and interventions in Egypt.
were accompanied by police officers during all observation days as per national rules. Data were entered and cleaned on-site and further cleaned and analyzed once transferred to JH-IIRU. Descriptive statistics were calculated to attain the baseline for the risk factors in the selected sites. The percentages of seatbelt use for drivers and front seat passengers were calculated for each round. Similarly, the percentages of vehicles driving above the speed were also tabulated. All analyses were conducted using STATA Statistical software (version 11) (StataCorp LP, College Station, TX). The study was deemed not human subjects research by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health (JHSPH).
Methods Results Primary data collection was carried out by JH-IIRU and CAPMAS with help from the WHO Egypt Country Office and the Ministry of Interior (MoI) on a highway (Cairo Ring road), and two urban roads crossing Alexandria city (Kornish and Gamal Abd Elnaser roads). Two rounds of seatbelt and child restraint observational studies and one round of speed observational studies were conducted. The two rounds of observational studies were carried out in June 2011 and March 2012 on Cairo Ring Road and October 2011 and March 2012 on the two roads in Alexandria governorate. Our research team used sampling frames provided by the Ministry of Interior (MOI) to randomly select four observation points for each road. This resulted in a total of 12 observation points for all three sites. A standardized observation protocol and data collection sheet were utilized to record speed, seatbelt, and child restraint use at the selected locations. All observers were trained staff in research methodology as well as in research ethics. For seatbelt and child restraint observations, the observers were divided into two teams of two for each road. Each team observed two sites twice a week (once during the weekday and once during the weekend) and each site was observed from 9:00 in the morning to 5:30 in the afternoon for four twohour periods. Only front-seat occupants (drivers and front seat passengers) were observed. For speed observations, observers used two moving radars for each road. The observation days and times were the same as that for the seatbelt study. All teams
Seatbelt and Child Restraint Use The total sample sizes for the two rounds of seatbelt and child restraint observational studies were 39,635 for Cairo Ring Road (Round 1: 17,643 and Round 2: 21,992 ), 40,167 for Kornish Road (Round 1: 18,978 and Round 2: 21,189), and 59,088 for Gamal Abd Elnasar Road (Round 1: 27,922 and Round 2: 31,166). The overall percentage of seatbelt use remained steady during the two observation cycles (Figure 1). On Cairo Ring Road, for example, findings from the first (10.9%) and second (11.1%) rounds were similar. Seatbelt use for drivers on all three roads was below 20% and ranged from 11.1% to 19.8% during the two observation cycles. As compared to the two other roads, the percentage of seatbelt use among drivers on Kornish Road was slightly higher for both rounds (18.5% and 19.8% respectively). As compared to drivers, the percentages of seatbelt use among front seat passengers were substantially lower for all three sites (less than or equal to 4.0%). When disaggregated by vehicle type, seatbelt use was much higher among private personal car drivers as compared to other types of vehicles (Table 1). This holds true for both rounds of observations and for all three roads except for taxi drivers on Cairo Ring Road. In contrast to the two roads in Alexandria governorate, the percentage of seatbelt use among taxi drivers on Cairo Ring Road is substantially higher and almost similar to the percentage of seatbelt use among private car drivers (range: 20.0% to 28.4%).
C. Hoe et al. / Injury, Int. J. Care Injured 44 S4 (2013) S45–S48
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Table 1 Seatbelt Use Among Drivers by Vehicle Type and Roads, Egypt, 2011-2012 Private Cars
Taxis
Light Trucks
Large Trucks
Buses
Microbuses
Cairo Ring Road 2011 2012
28.4% (n=2,023) 31.8% (n=2,166)
20.0% (n=317) 28.4% (n=464)
5.3% (n=148) 9.5% (n=328)
6.8% (n=214) 7.4% (n=306)
6.4% (n=57) 6.5% (n=151)
2.6% (n=54) 3.3% (n=121)
Alexandria’s Kornish Road 2011 2012
25.6% (n=3,275) 26.1% (n=3,847)
5.3% (n=176) 8.9% (n=315)
2.1% (n=8) 1.5% (n=8)
2.6% (n=3) 4.7% (n=6)
3.1% (n=9) 1.0% (n=4)
2.2% (n=45) 0.9% (n=16)
Alexandria’s Gamal Abd Elnaser Road 2011 2012
25.9% (n=3,222) 20.4% (n=2,788)
6.1% (n=511) 5.8% (n=597)
3.3% (n=42) 3.2% (n=40)
3.0% (n=7) 2.3% (n=6)
0.9% (n=7) 0.7% (n=4)
0.9% (n=42) 0.3% (n=16)
Table 2 Seatbelt and Child Restraint Use Among Drivers in Cars with Children, Egypt, 2011-2012 % of seatbelt use among drivers in cars with children
% of children sitting in the front seat
% of children sitting in the front seat and wearing seatbelt
% of children sitting in child seat
Cairo Ring Road 2011 2012
21.8% (n=1,912) 17.2% (n=2,564)
40.6% (n=1,915) 42.2% (n=2,564)
7.6% (n=778) 10.0% (n=1,081)
1.9% (n=1,910) 3.9% (n=2,564)
Alexandria’s Kornish Road 2011 2012
22.2% (n=2,600) 17.4% (n=3,415)
36.5% (n=2,784) 33.1% (n=3,447)
3.2% (n=1,011) 3.0% (n=1,142)
2.8% (2,782) 3.0% (n=3,445)
Alexandria’s Gamal Abd Elnasar Road 2011 2012
17.1% (n=3,404) 5.7% (n=4,291)
40.9% (n=3,407) 41.4% (n=4,293)
12.2% (n=1,392) 4.8% (n=1,775)
1.4% (3,407) 1.1% (n=4,293)
A larger proportion of drivers in cars with child occupants use seatbelts as compared to drivers in cars without child occupants (Table 2). This holds true for both rounds of observations on Cairo Ring Road (21.8% and 17.2% as compared to 15.9% and 16.1%), the first round of observations on Kornish Road (22.2% as compared to 18.5%), and the first round of observations on Gamal Abd Elnasar Road (17.1% as compared to 13.7%). With regards to child occupants, a large proportion was found to be sitting in the front seat of the vehicle. This finding was consistent across all three roads and for both rounds of observations (range: 33.1% to 42.2%). Only 3.0% to 12.2% of these front seat child occupants wore seatbelts. The percentage of children sitting in child seats was also low (1.1% to 3.9%) on all three roads (Table 2). Speed Figure 2. Percent of Vehicles Driving Above Speed Limit by Road, Egypt, 2011.
The total sample sizes were 13,705 for Cairo Ring Road, 26,498 for Kornish Road, and 20,199 for Gamal Abd Elnasar Road. Findings showed that of the three roads, Kornish Road had the highest overall percentage of vehicles driving above the speed limit (39.4%; n = 26,498). Whereas 22.6% (n = 13,705) and 11.8% (n = 20,199) of drivers on Cairo Ring Road and Gamal Abd Elnaser Road exceeded the speed limit, respectively (Figure 2). When disaggregated by number of kilometers above the speed limit, the majority of the vehicles that exceeded the speed limit on all three roads drove 1 to 10 kilometer above the speed limit (Figure 2). For Cairo Ring Road, 47.5% of large trucks and 44.4% of microbuses exceeded the speed limit as compared to 5.4% of taxis. On Kornish Road, buses tended to speed most (52.3%) and trucks tended to speed less (light trucks: 20.3% and large trucks: 20.4%). On Gamal Abd Elnaser Road, the percentage of vehicles exceeding the speed limit was less than 12% across all types of vehicles except for buses, where 20% of the drivers drove above the limit (Table 3). When disaggregated by time of day, results showed that the percent of vehicles exceeding the speed limit on
Cairo Ring Road was consistent throughout the day (Range: 20.7% to 24.2%). This is also true for Gamal Abd Elnaser Road (Range: 10.1% to 14.1%). Kornish Road, on the other hand, experienced a higher percentage of vehicles speeding in the mornings; more than half of the vehicles were observed to be speeding during 9 am to 11 am, and around 40% were observed to have exceeded the speed limit during the 11 am to 1 pm time period. Discussion Road traffic injuries are a major public health problem in Egypt and efforts to address major risk factors such as increasing seatbelt and child restraint use, as well as managing speed are critically important. Results from this study revealed that that seatbelt usage was low on all three roads during two observation cycles; this is consistent with existing studies in this area.9 Similar to regional trends, our findings also showed that, when disaggregated by the type of front seat occupants, the percentage
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Table 3 Percent of Vehicles Driving Above the Speed Limit by Vehicle Type, Egypt 2011
Cairo Ring Road Alexandria’s Kornish Road Alexandria’s Gamal Abd Elnaser Road
Private Cars
Taxis
Light Trucks
Large Trucks
Buses
Microbuses
26.8% (n=6126) 40.0% (n=18,646) 12.0% (n=14,515)
5.4% (n=3,069) 37.9% (n=894) 9.9% (n=1,249)
25.0% (n=2,819) 20.3% (n=158) 11.7% (n=94)
47.5% (n=522) 20.4% (n=944) 8.0% (n=587)
28.7% (n=1,160) 52.3% (n=3,472) 20.0% (n=1,464)
44.4% (n=4) 25.1% (n=2,384) 7.2% (n=2,290)
Speed limits: Cairo Ring Road: 90 kilometer/hour for private cars and taxis, 70 kilometer/hour for microbuses and trucks (light and large), and 80 kilometer/hour for buses; Alexandria’s Kornish and Gamal Abd Elnaser: 60 kilometers/hour for all types of vehicles.
of seatbelt use was substantially lower for front seat passengers as compared to drivers. One of the factors that may explain such low seatbelt usage in the country is the level of enforcement. According to the 2013 Global Status Report on Road Safety, seatbelt enforcement in Egypt was rated a “5” on a scale of 10 revealing that there is room for improvement.3 Our study also showed that child restraint use was very low for all selected sites and about two-fifths of the child occupants were found to be sitting in the front seat of the car. These results could be explained by the fact that, similar to other countries in the region, Egypt currently lacks a child restraint law.10 Although the enactment of such a law does not guarantee 100% coverage, it is likely to increase the percentage of child restraint use, particularly if paired with strong enforcement. A systematic review conducted by Zaza et al in 2001, for example, revealed that child restraint laws not only increases child safety seat usage but also decreases non-fatal and fatal injuries.11 Attention will need to be focused on changing current practice of allowing children to travel unrestrained in the front seat of passenger cars. The burden of speeding is also high in Egypt; among all roads, Kornish Road in Alexandria governorate had the highest percentage of vehicles exceeding the speed limit (39%). A literature review conducted by Puvanachandra et al in 2012 showed that academic studies pertaining to speed in Egypt currently do not exist.8 As with seatbelt use, one of the factors that may explain speeding is the level of enforcement. According to the 2013 Global Status Report on Road Safety, speed enforcement was also rated a “4” on a scale of 10.3 This study had several limitations. First, due to the political situation of the country, we were only able to conduct two rounds of observations for seatbelt and child restraint use and one round of observations for speed. While the results were generally consistent between the two rounds for seatbelt and child restraint use. More rounds are needed for a reliable baseline. Second, we were only able to observe two risks factors on three national highways and at specific times of day (9 am to 5:30 pm). Although findings did provide some insight about the issue, they are not nationally representative. Finally, the three sites were roads rather than populations, hence the individuals who drive on these roads may not necessarily be from these respective governorates of Cairo and Alexandria. Thus, these results are also not representative of these cities. As Egypt continues through its phases of political transitions, we hope that efforts towards road safety will be prominent. In 2012, Puvanachandra et al highlighted the steady improvements of the country’s data system; it is critical that such momentum is ensured in the future. Future interventions also need to focus on enhancing enforcement, standardizing existing data systems, and closing gaps in legislation such that child occupants are mandated to wear child restraints.
Conflict of interest All authors declare no conflict of interest. Acknowledgements This work was conducted as part of the Global Road Safety Programme in Egypt, funded by Bloomberg Philanthropies. We would like to thank Central Agency for Public Mobilization and Statistics, Ministry of Interior, Ministry of Health, World Health Organization Country Office and Eastern Mediterranean Regional Office, Global Road Safety Partnership as well as Association for Safe International Road Travel for their cooperation in the project. Authors’ contributions All authors have made substantial contributions. PP and AAH developed the study design. CH, PP, HR, HS, SE, AE, MA oversaw data collection; CH led the data analysis and prepared the manuscript. All authors reviewed the final version of the manuscript. References 1.
Institute for Health Metrics and Evaluation. Global Burden of Diseases, Injuries, and Risk Factors Study 2010. http://www.healthmetricsandevaluation.org/ gbd/research/project/global-burden-diseases-injuries-and-risk-factorsstudy-2010. 2. World Health Organization. The global burden of disease: 2004 update. Geneva: World Health Organization; 2008. 3. World Health Organization. Global status report on road safety: time for action. Geneva: World Health Organization; 2013. 4. Hyder AA, Allen KA, Di Pietro G, Adriazola CA, Sobel R, Larson K, et al. Addressing the implementation gap in global road safety: exploring features of an effective response and introducing a 10-country program. Am J Public Health 2012;102:1061-7. 5. Central Agency for Public Motorization and Statistics. Annual Statistics Report. Cairo, Egypt: CAPMAS; 2009. 6. Ministry of Health Egypt, World Health Organization. Injury Surveillance Report 2010. Cairo, Egypt: Ministry of Health Egypt Prevention Health Sector, Occupational Health Department, Injury Control Unit; 2010. 7. World Health Organization Regional Office for the Eastern Mediterranean. About Road Traffic Injuries. Geneva: WHO; 2009. 8. Puvanachandra P, Hoe C, El-Sayed F, Saad R, Al-Gasseer N, Bakr M, et al. Road Traffic Injuries and Data Systems in Egypt: Addressing the Challenges. Traffic Inj Prev 2012;13(Suppl 1):44-56. 9. Rady M. Behavioral Risk Factors Among Physicians. J Egypt Public Health Ass 1997;72; 233-56. 10. Soori H, Hussain SJ, Razzak JA. Road safety in the Eastern Mediterranean Region – findings from the Global Road Safety Status Report. EMHJ 2011;17:770-6. 11. Zaza S, Sleet D, Thompson R., Sosin D, Bolen J. The Task Force on Community Preventive Services. Am J Prev Med 2001;21(Suppl 4):31-47.
